Healthcare Capstone: Unit 7

Healthcare Capstone

Spring Session 2

Marina Gizzi

Sunday, April 15th 2018

Pay-for-performance initiatives have been recently suggested to be the best means of improving the underlying quality of patient care as well as offering incentives to advance providers' performance. Moreover, the Centers for Medicare coupled with the Medicaid Services have approved the programs to be advancing quality of care (Srinivasan & Desai, 2017). The pay-for-performance model normally provides financial incentives to the existing providers namely the physicians, hospitals, and in bid to improve the quality as well as efficiency (Murphy et al., 2016). Basically, incentives are normally paid above the standard fee-for-service compensation in case the provider achieves or surpasses particular pre-established metrics in regard to performance. Moreover, certain models penalize the providers when they fail to accomplish the predetermined performance standards as well as particular conditions such as medical mistakes coupled with the hospital readmissions.

The payer, which typically encompasses the insurance company, Medicare or Medicaid utilizes administrative as well as claims data to undertake assessment of the underlying provider performance mainly based on the process, outcomes, patient satisfaction as well as structure (Pronovost et al., 2015). The process mainly entails activities that have been depicted to advance patient results like counselling of the patient while outcome entail the impacts that the existing provider care had on the corresponding patient health. Patient satisfaction entails the patient view pertaining to the quality as well as the delivery of the care (Murphy et al., 2016). Moreover, the structure entails the established facilities, personnel coupled with the equipment utilized during delivery of the care such as electronic medical records. CMS initiated its first pay-for-performance pilot program in the year 2003n as the Premier Hospital Quality Incentive program. Since the time the program was launched, the organization has taken part in numerous demonstration projects that have tested a variety of pay-for-performance techniques for diverse kinds of the providers (Markovitz & Ryan, 2017). Moreover, the Affordable Care Act (ACA) has extended the utilization of the pay-for-performance programs within the Medicare thus experimentation to assess program effectiveness. The paper mainly aims as exploiting and assessing numerous ways through which CMS pay for performance incentives within hospitals escalates quality health results.

The latest study has established no distinct evidence that the underlying value-based reimbursement models that pay for performance aids in advancing patient outcomes (Pronovost et al., 2015). The notion of offering financial incentives to the existing health care givers mainly to advance the quality of care commonly known as pay for performance, has received national interest as a potential way of narrowing well-documented gaps that exist amidst the health care guidelines and the corresponding clinical practice. In partnership with the Premier Inc, a countrywide organization of the nonprofit hospitals, the Centers for Medicare & Medicaid Services (CMS) initiated the Hospital Quality Incentive Demonstration (Murphy et al., 2016). As section of the program certain organizations has offered measurement information for the five primary clinical conditions with the inclusion of the acute myocardial infarction.

Hospitals with the two highest deciles in regard to the performance for the situation received a reimbursement bonus whereas the ones with those with the poorest performance risked prospective financial penalty (Markovitz & Ryan, 2017). Moreover, the internal study of the incentive program has established that the underlying composite performances scores escalated considerably for the selected five conditions during the duration of the program demonstration and were mainly related to the advancements in terms of the mortality at the respective participating hospitals (Srinivasan & Desai, 2017).

The latest published assessment of the effect of the incentive [program have depicted a modest positive incremental impacts on the underlying hospital performance. Nevertheless, these assessments left numerous unanswered fundamental questions concerning the effectiveness as well as the probable consequences pertaining g to the pay-for-performance programs (Markovitz & Ryan, 2017). The questions pertain to the incremental advantage of the pay for performance in regard to the processes of care in comparison with the more traditional quality-improvement efforts like the voluntary quality-improvement registries (Pronovost et al., 2015). Another question pertaining to the effectiveness’ of the program regard whether the hospitals will be becoming unduly concerned on the specific such as the graded care processes to the corresponding detriment of the unrewarded aspects of the care. Moreover, the last questions pertain to the measurement of the improved entire patient outcomes by the pay-for-performance incentives that mainly target solely a few chosen process measures (Milstein & Schreyoegg, 2016).

Specifically, the paper will assess whether hospitals taking part in using the pay-for-performance program have depicted any substantial advancement in regard to the process measures as well as the outcomes for the acute myocardial infarction past that established within the hospitals not taking part within the program. I will also assess the impact of the pay for performance on other important processes of care as recommended by the renowned ACC/AHA national strategy with the exclusion of the underlying financial incentives.

Srinvasan, D., & Desai, N.R. (201) The impact of the transition from volume to value on heart failure care: implications of novel payment models and quality improvement initiatives. Journal of cardiac failure, 23(8), 615-620. Srinvasan and Desai jointly analyze the impact of change of tact from volume to value to help in quality improvements. They suggest that the United States health care system is moving away from the volume-based payment method to a quality and value-based method. This suggest that the payments are made based on performances and not on the quantity of work as it was in the previous system of payment. In the article, the authors have highlighted some of the programs that financially penalizes healthcare facilities for excess readmissions. In particular the focus of the article is on Hospital Value-Based Purchasing, Bundled Payment for Care Improvements, the Merit-Based Incentive Payment System, and Accountable Care Organizations. These programs are aimed at improving the quality and enhancing cost efficiency among those who seek health care services.

Milstein, R., & Schreyoegg, J. (2016). Pay for performance in the inpatient sector: A review of 34 P4P programs in 14 OECD countries. Health Policy, 120(10), 1125-1140. Milstein and Schreyoegg review some of the pay programs to see which ones bring about improved performance in the inpatient sector. The article provides an overview of 34 existing P4P programs, which are based on structure literature research in various countries. In the overview, evaluations of such programs are made to allow for conclusions be made in regards to whether such programs and in deed living up to their expectations. From the article, it is suggested by the authors that the impact of P4P programs is unclear and that this maybe as a result of moderately positive effects seen from some of the programs that arise from the side effects. The authors make a recommendation that policy makers have to decide whether the potential benefits of the programs outweigh the risks.

Markovitz, AA., & Ryan, AM. (2017). Pay for performance: Disappointing results or masked heterogeneity? Medical Care Research and Review, 74(1), 3-78. Markovitz and Ryan indicates in the article that research shows disappointing results on the effects of pay for performance (P4P) in the health care. According to the authors, the finding is important in masking the heterogeneity in the effects of P4P programs. The authors go further to provide a literature view to help in assessing whether physician and health performance in P4P vary by catchment area factors, patient, organizational and structural capabilities, and the programs characteristics. Through the literature review that is conducted by the authors, they reach at several findings. One of the findings is that the size of the organization, status of teaching, type of practice, and physician gender and age are some of the intervening factors in the performance of P4P. It was also found by the authors that a higher proportion of poor and minority patients are strongly associated with worse performance. Information technology and staffing levels bring about mixed results. The authors conclude by providing that extant heterogeneity in the effects of the programs does not have fundamental alterations in the current assessments about its effectiveness.

Murphy, D. J., Lyu, P. F., Gregg, S. R., Martin, G. S., Hockenberry, J. M., Coopersmith, C. M., & Sevransky, J. (2016). Using incentives to improve resource utilization: A quasi-experimental evaluation of an ICU quality improvement program. Critical care medicine, 44(1), 162. This is an experimental research that has ben conducted by many individuals as indicated above. The objective of the experiment is to know how healthcare systems strive to provide quality care at lower cost. In conducting the research, the authors look at issues such as chest radiographs, gas testing, and RBC transfusions in relation to how they provide an important example of opportunities that can be used to reduce excess resource utilization within the ICU. The authors also go ahead and describe the effects of multifaceted quality improvement program that is aimed at decreasing the avoidable arterial blood gases, and RBC utilization of these resources in regards to bring good patient outcomes. The conclusion of the authors after the experiment is that implementation of a multifaceted quality improvement program, which includes financial incentives are associated with significant improvements in the resource utilization. The authors argue that their findings provide evidence supporting the safety, sustainability and effectiveness of incentive-based quality improvement interventions.

Pronovost, P. J., Armstrong, C. M., Demski, R., Callender, T., Winner, L., Miller, M. R., ... & Reitz, J. A. (2015). Creating a high-reliability health care system: Improving performance on core processes of care at Johns Hopkins Medicine. Academic Medicine, 90(2), 165-172. In this article, the authors describe an initiative that has established an infrastructure to help manage the safety and quality efforts through the always complex health care system. This includes the improved performance in some of the core measures for the acute myocardial infarction, pneumonia, children’s asthma, and surgical care among others. The authors in achieving the objective of the article take a look at the Johns Hopkins Medicine Board of Trustees, which created a governance structure to help create health care system-wide oversight for purpose of accountability within the facility. The article has also based in information on the Armstrong Institute for Patient Safety and Quality, which use conceptual model nested in fractal infrastructure to help in the implementation of the initiative aimed at improving performance at the two-academic medical center and three community hospitals.

As compared to any other industrial country, United States of America spends a lot of money per capita on health care. In the year 2009, the US per capita on health care was $7,960. Their expenditure on health care is about fifty percent more than the spending of other countries. The huge spending by the United States of America might be reasonable if the value of the healthcare and health in the US outranked by other nations (Obama, 2016). The United States of America insulates behind many of the other industrial countries in numerous pointer of health and the quality of health care. The following reason explains why the cost of healthcare in the United States is very high:

The administrative costs of operation health care systems in United State are exorbitant. In the cost of the healthcare, about one-quarter of it is associated with administration, this amount is very high as compared to any other nation. The main reason for higher costs of administration: in public sector health systems, the number of clerks in the billing system is much; in US providers of health care must negotiate the rates of payments separately with each deal and payer with billing procedures and variety of requirements (Squires, 2012).

The cost of drugs in the US is also another main dissimilarity in health costs with the other developed countries. Politicians and the public believe that drug costs are unreasonable. In many countries, the government is the one responsible for the negotiation of drug prices with the people responsible in making drugs, in the US when the Congress formed the Medicare Part D; it exclusively denied the Medicare the power to use its right to negotiate the prices of drugs. The Medicaid and the Veteran’s Administration, which can negotiate the prices of drugs, give the lowest prices on drugs. The budget of congressional office found that giving low-income receivers of Medicare part D equal money off to recipients of Medicaid get the centralized government would have saved more in the coming years.

Drug companies in America set prices for their drug. Government and insurance will then cut down those prices using ways that will differ from patient to patient (Squires, 2012). Medicare assists to raise this prices, when doctors sell drugs at higher prices, they receive rewards. Medicare does not negotiate with companies that manufacture drugs since it is illegal. Rules of Medicare for inhalers and pills are evenly senseless. The government supports the Medicare issue of not bargaining but private insurers do so instead. When drugs come out for the first time in America, the price is very high, but as the drug gets older the price is lower. Researchers have found that differences in price are smaller for antibody-based medicines that are used to treat rheumatoid arthritis and cancer conditions.

Defensive medicines are another driver of why the costs of healthcare are very high in the US. Medical practitioners are afraid of getting sued, thus they have to carry out many tests even if they know what the diagnosis is. Surveys done shows that annually about $650 billion could be accredited to defensive medicine. Every person pays the bill with insurance premiums that are very high, out-of-pocket costs and co-pays, also the taxes that are used to pay for healthcare programs for the government. A big number of medical practitioners in the United States health care facilities order for more procedures and tests such as computed tomography, electrocardiograms, sonograms, magnetic resonance imaging and biopsies, these tests are very expensive. Most doctors order for many tests since they fear to diagnose a patient wrongly, the trust that they will not get protection from the lawsuit.

Medical practitioners in the United States use much expensive mix treatment. Comparing the United States with other developed countries, for instance, the United States of America uses two and a half times of the thirty-one percent cesarean sections and the number of Magnetic resonance imaging, three times more mammograms. This leads to more usage of technology, also many people in the United States are treated by professional, these professionals ask for much higher fee on treatments than the normal doctors, this contributes to expensive mix treatments, in other developed countries this kind of treatments are provided by primary-care at a standardized price (Squires, 2012).. In the United States, higher pays that are asked by professionals makes the cost of mix treatments very expensive. The cost of Outpatient hospital services and in Emergency rooms services are very high, thus this contributes to high costs.

Use of more technology raises also the cost of a mix of treatment. Comparing to other industrialized countries, United States of America uses more complicated diagnostic technology. According to analysis, it was found that America had the top per capita rates of positron emission tomography, computed tomography, and magnetic resonance imaging.

Health care sectors are considered as non-profit industries in many countries. In the United States of America, the healthcare sector is more of a profitable industry that has made doctors to get higher salaries to administrators of hospitals to executives of health insurance. Among the best-paid doctors in the world are the US doctors. But all they earn is not because of care they deliver but it is from supervision of medicine business. The pay of hospital administrators, health insurance executives and hospital executives often far surpass the salaries of doctors.

In the United States of America, the cost of health care services differ wildly, this is due to lack of transparency in the price of their services. More often, patients get their bills after services. The bills are different even though the services are the same, insurance determines the cost. Studies have shown that there is a connection between the quality and cost of the healthcare (Obama, 2016).

Using market forces as a barrier to bringing down the costs of healthcare by consumers is an impossible task. In modern years, a number of initiatives have been put in place to improve transparency, those initiatives comprise of cost-estimator tools. These initiatives even though have hard small impacts on the behavior of the patient. The reason is that decisions about health care are protected to cost-shopping since they involve inpatient care, emergencies this has no difference in the costs. Uses of cost-comparisons by other people choose services that are very expensive since they link quality and price.

Despite the fact that hospitals provide health care to individuals, they are the most hazardous places to work to both patients and the workers. Hospital environment need to be an example to other organizations since the hospital is a centre for health purposes. Workers fail to deliver their services in a satisfactory manner due to poor working environment the act which brings more harm to the patients due to poor service delivery. (Burke, 2003). Most common hazards found in the hospital include lifting and moving of the patients, strips slips, and falls, and the potential for comparative or agitated or the visitors along with a unique culture, dynamic and unpredictable environment. Caregivers feel good to help patients by causing no harm to them and some even putting their own safety and their health at risk in order to help the patients.

The recent studies have shown work to be surprisingly dangerous. According to statistics from the labor bureau, it shows that, the labor injuries or illness that results away from work is higher in the hospitals than any other work place including manufacturing and constructions which are believed to be more dangerous to workers if not handle with a lot of care. These injuries come at high cost to the hospitals more especially when employees gets hurt in the job, hospitals pay prices of compensation to workers for the lost wages and medical costs, overtime when injured employees miss work, back lifting, turnover costs incurred when employees quit the job because of severe injuries, temporary staffing, morale as the employees become emotionally and physically fatigued and deceased productivity. Apart from the workers, work place safety also affects the service care to patients. Manual lifting can also injure caregivers and put the patients at risk of falls, skin tears, bruises and fractures. Fatigue, injury, and stress of the caregiver are tied to the risks of patient infection and medical errors.

The rates of injuries and illness according to research compute to a rate of 6.8 illness and work related injuries for every 100 full time employees in the United States of America hospitals. The injuries of illness and injuries in the hospital doubles the private industries and these are higher than the construction rates and manufacturing companies. Severe injuries can lead to workers missing the work by being assigned to modified study. Looking at the total case, hospitals have a high rate of days away cases than the construction than the manufacturing companies or the private industries. Hospitals have a high rate of injuries than business and any other industries. In order to understand more about hospital safety, there should be collaboration between hospital managements and the workers and patients so as to foster safety and quality service delivery.

Health care injuries can be broken down to different sectors out of which nursing homes are the leading away injuries. The sectors include:

· Hospitals

· Ambulatory healthcare services

· Nursing and residential care facilities

The divisions are done specifically because in addition to some of the general musculoskeletal issues that are faced by almost every industry, healthcare deal with unique hazards like the needle sticks. These injuries may come as a result of biological agents, blood bone pathogens, radiation and the lasers. There are also back injuries like lifting, pushing and pulling.

Healthcare injuries can be grouped into different distinct groups like blood borne pathogen exposures, slips, chemical exposures, falls and trips and also back injuries. The following are the common issues that safety officers face in the work places.

The bureau of labor and statistics do not break the injuries down according to the type. This cannot be said that it is impossible to categorize the healthcare injuries according to their type. Injuries like needle sticks are more likely in elevation of the healthcare work injury recording a high rate above other industries. According to OSHA there are estimates that there are roughly 800,000 needles stick injuries in every one year. Despite the fact that it has tried to reduce the number of healthcare injuries resulting from the needle sticks, still operating rooms faces the biggest ascending battle. Needles are useful during surgeries and many other related usages. According to OSHA, it has recommended that the surgeons should use the blunted suture needles but this cannot work but they can only be used in certain situations and the safety scalpels do not always offer the precision foe the regular scalpels.

Apart from use of needle in surgery, needle can also cause injuries due to poor exposures. General exposure injuries also have resulted to high risks in the health unities. This exposure results in the purchase of unsafely needles that are not effective for use. If an injury occurs in the surgeon room for instance, the patient will be at risk to receive quality services because of the pains and bleeding of the nurses in the operation which may result the nurse to delay in offering services to the patients the act which may put the patient at risk. For the general exposure, the protection measures that should be taken into place include safety officers should be involved with the purchasing of the safety needles effective and easy to use. On the side of the employees, they should also be trained on how to use the safety needles in order to reduce the risks of the sharp injuries.

Back injuries include musculoskeletal injuries. Musculoskeletal injuries are big in the health care facilities. These injuries mostly occur among the aides and the nurses who need frequently to pull, push and turn heavy patients. Despite the fact that many hospitals have involved in the purchase of the devices which helps with lifting and instituting of the team lifting programs to put the nurses at a saver side to help the workers to lift and avoid back injuries to attack them, the number of back injuries are still experienced because the employees are always too busy to employ the proper methods required to handle the devices in a proper way. There is a high rate of knee and the back injuries results from the employees pushing the patients in the wheelchair. The injuries come in such that there is a high rate of patients requiring the lift giving the workers difficult times to lift them from one place to another for a long time giving them backache and this result to back injuries makes the employees ill.

There are also some of the risks that employees are always injured inside the facility by slipping on the wet surface or tripping over the equipment. These injuries come when employees goes and comes from the parking lot. Slipping of the employees occurs as a result of slippery surfaces in the hospital premises. During the season of winter, there is heavy snow falls and icy sidewalks, parking lots, entrances make the outdoors to remain precarious during this winter months. The hospitals should have a plan of sufficiently clearing the pathways during the season of winter storms and have the appropriate equipments for drying the surfaces like the salts plows and the shovels in order to prevent unnecessary falls outside the building.

In general the healthcare workers are now aware of the risks they always face during the job in daily basis. However sometimes the problem rise when competing of the interests takes a priority over the safety measures which makes the workers at higher risks.

Avoiding the pitfalls and higher priorities of human nature, the officers need to incorporate safety measures seamlessly into the everyday risks tasks. As an example of how not to do the things, the US portal services, which are, required the reeducation for the injured workers on the proper lifting techniques.

The only trick is that, integrating safety measures to workers’ routines by not taking too much time during the procedures to actively think about the safety. According to the research, the results found that, the mostly injured workers in the hospitals are the highly educated employees. This shows that the retraining never reduced the amount of injuries to the employees.

The group to be blamed on the hospital injuries to workers and the patients is the leadership of the hospitals. This is because the leaders are the ones to ensure safety to the workers and patients rather than the victims only. The hospitals are at high rate of employing more workers but in the really sense they don’t bother on the safety of the workers themselves. The leaderships to be blamed include the CEOs and the treasuries since these are the people responsible of, making changes in any organization to help individuals and the patients experience safety.

The leadership of the most hospitals is not unique since they serve the snapshot of the facilities in the country. In the University of Pittsburgh medical center for instance, employs almost 54,000 workers. Unfortunately the leadership at the hospital not unique since it serves the snapshot of the country.

There are more injury rates in the healthcare because looking at the general matter, the people in charge of the health and the medical facilities don’t care about other people below them. This creates a lot of differences in the work place and leads to careless handling of the tools which later cause injuries in both the workers and the patients. If the health care officers would have cared for other people under them, they would have been free to learn from other organizations that it is very easy to be in an injury free workplace and this will; make them make their precondition for their work.

The leaders therefore, need to set up aggressive goals for their organizations starting with the objective that no one should get hurt in the workplace. The leaders should backup the objectives with the systematic action plan that will eliminate and improve the workplace injuries.

Another relevant example is the Cincinnati Children’s Hospital. The hospital publishes the injury rates, which are significantly lower compared with other hospitals. The company involved itself in train on and teaming within the Celanese, a chemical company with the excellent history of the safety of the workers. (Singer et al 2009). The Celanese was able to show the healthcare system ways to eliminate virtually all injuries which enable the children’s home to adopt some of the safety principals from the manufacturing and the chemical industry. The hospital achieved by reducing the number of risks because of the responsible leaders who cares for the lives of both the workers and the patients and the entire management.

The reason why there is always detriments of the safety of the workers, is because the hospitals focuses on the smaller projects which are devoted in a particular area, rather than focusing on overcharging excellence systems. There have been more concentrated levels of attention that is aped to certain kinds of the hospital acquired.

The healthcare waste management policies and plans should have the continued supervision and monitoring of the worker's safety and the health inclusive in order to ensure collect treatment, handling, storage and the disposal procedures are correctly followed. The necessary measures to be taken by the management should include the following:

· Proper workers training

· Establishment of the effective occupation health program that include post exposure treatment of prophylactic immunization and medical surveillance.

· Provision of clothing and the equipment for personal protection

When conducting the training, the management should ensure that the workers are well educated and understands well of the potential risks that are associated with the healthcare wastes , the importance of personal and proper use of protection equipment’s and the value that can be incurred in case of immunization against the viral.

The workers who are fond of being found at risk include the healthcare providers, the maintenance workers, the cleaners of the hospitals the operators of the waste equipment treatment and all other operations that are involved in handling of the water and outside disposals and within the healthcare premises.

Hospital management should ensure that the workers are protected during production, segregation, treatment, transport and healthcare disposal waste which involves the handling of the potentially hazardous materials. Therefore, it is very essential if workers who are at risk are well protected. The responsible management of the individuals of the healthcare should ensure that all the risks are identified and provide the suitable protection against the risks.

If a comprehensive risk assessment of all of the activities that are involved in the healthcare waste management are carried out during the waste management plan preparation, will allow the necessary protection measures identification. The measures should be therefore, be designed in order to prevent the exposure to other risks or hazardous materials or keeping the exposure within the safe limits. Once all of these precautions are taken into consideration, the workers therefore are at the position to begin training.

The wearing of the protective clothes will depend to an expense at which the risk is associated with the healthcare waste. The following should be made available to the personnel collecting and handling the healthcare wastes:

· Wearing of the helmets with or without visors depending on the type of the work taking place.

· Wearing of the face masks depending on the task

· Eye protectors

· Overalls

· Leg protectors

· Dispose grove

The industrial boots and the heavy groves are important particularly for the waste workers. The tick sores of the boots protect the workers from getting injured by the spilled sharps and slippery floors. If the disposal of wages places is inadequate, to is then important to place the sharp items like the needles in plastic bags or weak plastic containers. Basic personal hygiene is also very important in the reduction of the risk from. Handling of the healthcare waste and convenient washing of the facilities with warm water and soap should be available at the personnel involvement tasks will help to minimize risks that might occur in the working place. Immunization is also very important Incas the worker has got ill in the work place.

Reference List

Burke, J. P. (2003). Infection control--a problem for patient safety. The New England journal of medicine, 348(7), 651.

Clarke, S. P., Sloane, D. M., & Aiken, L. H. (2002). Effects of hospital staffing and organizational climate on needle stick injuries to nurses. American journal of public health, 92(7), 1115-1119.

Markovitz, A. A., & Ryan, A. M. (2017). Pay-for-performance: Disappointing results or masked heterogeneity?. Medical Care Research and Review, 74(1), 3-78.

Milstein, R., & Schreyoegg, J. (2016). Pay for performance in the inpatient sector: A review of 34 P4P programs in 14 OECD countries. Health Policy, 120(10), 1125-1140.

Murphy, D. J., Lyu, P. F., Gregg, S. R., Martin, G. S., Hockenberry, J. M., Coopersmith, C. M., ... & Sevransky, J. (2016). Using incentives to improve resource utilization: A quasi-experimental evaluation of an ICU quality improvement program. Critical care medicine, 44(1), 162.

Obama, B. (2016). The United States health care reform: progress to date and next steps. Jama,

316(5), 525-532.

Pronovost, P. J., Armstrong, C. M., Demski, R., Callender, T., Winner, L., Miller, M. R., ... & Reitz, J. A. (2015). Creating a high-reliability health care system: Improving performance on core processes of care at Johns Hopkins Medicine. Academic Medicine, 90(2), 165-172.

Singer, S., Lin, S., Falwell, A., Gaba, D., & Baker, L. (2009). Relationship of safety climate and safety performance in hospitals. Health services research, 44(2p1), 399-421.

Srinivasan, D., & Desai, N. R. (2017). The impact of the transition from volume to value on heart failure care: implications of novel payment models and quality improvement initiatives. Journal of cardiac failure, 23(8), 615-620.

Squires, D. A. (2012). Explaining high health care spending in the United States: an international

comparison of supply, utilization, prices, and quality. Issue brief (Commonwealth Fund), 10, 1-14.