Sylvia H. Hsu

Hospice is central to end-of-life care. Yet to receive hospice services, Medicare beneficiaries need to forgo treatments related to their terminal conditions.¹ Thus, patients with cancer cannot receive radiotherapy or chemotherapy, such as single-fraction radiotherapy for painful bone metastasis, for palliative purposes. To alleviate this constraint, some hospices have developed open-access programs that allow patients to receive care for their terminal conditions.² These hospices, however, encounter an increase in costs without an accompanying increase in reimbursement. In 2016, the Centers for Medicare & Medicaid Services initiated the Medicare Care Choices Model (MCCM), which allows participating hospices to provide care for beneficiaries’ terminal conditions and receive a higher payment rate.³ Despite this, very few hospices participate in the MCCM. To date, little is known about trends in hospices providing palliative radiotherapy and chemotherapy. This topic is particularly important now, as hospices may be reluctant to provide new, expensive immunotherapies.

Objectives: Hospice use reduces costly aggressive end-of-life (EOL) care (eg, repeated hospitalizations, intensive care unit care, and emergency department visits). Nevertheless, associations between hospice stays and EOL expenditures in prior research have been inconsistent. We examined the differential associations between hospice stay duration and EOL expenditures among newly diagnosed patients with cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and dementia.

Methods: In the Surveillance, Epidemiology, and End Results–Medicare data, we identified 240 246 decedents diagnosed with the aforementioned conditions during 2001 to 2013. We used zero-inflated negative binomial regression models to examine the differential associations between hospice length of services and EOL expenditures incurred during the last 90, 180, and 360 days of life.

Results: For the last 360 days of expenditures, hospice stays beyond 30 days were positively associated with expenditures for decedents with COPD, CHF, and dementia but were negatively associated for cancer decedents (all P<.001) after adjusting for demographic and medical covariates. In contrast, for the last 90 days of expenditures, hospice stay duration and expenditures were consistently negatively associated for each of the 4 patient disease groups.

Conclusions: Longer hospice stays were associated with lower 360-day expenditures for cancer patients but higher expenditures for other patients. We recommend that Medicare hospice payment reforms take distinct disease trajectories into account. The relationship between expenditures and hospice stay length also depended on the measurement duration, such that measuring expenditures for the last 6 months of life or less overstates the cost-saving benefit of lengthy hospice stays.

This study examines whether difficult targets and quality indicators in executives’ pay‐for‐performance (P4P) plans affect performance. The impact of target‐setting and P4P plans on quality improvement in the public sector is unclear. The Ontario government initiated the Quality Improvement Plan (QIP), which requires hospitals to set targets for quality indicators annually and link executive pay to target achievement since 2011. Analyzing Health Quality Ontario’s database and hospitals’ 2012–2013 QIPs, this study shows greater quality improvement in hospitals with difficult targets than hospitals with easy targets or without assigned targets; however, the positive impact disappears for high‐performance hospitals relative to their peers. We find no significant effect of the use of quality indicators in executives’ P4P plans on quality improvement. Copyright © 2018 ASAC. Published by John Wiley & Sons, Ltd.

Background: Although the fragmentation of end-of-life care has been well documented, previous research has not examined racial and ethnic differences in transitions in care and hospice use at the end of life.

Design and Subjects: Retrospective cohort study among 649,477 Medicare beneficiaries who died between July 2011 and December 2011.

Measurements: Sankey diagrams and heatmaps to visualize the health care transitions across race/ethnic groups. Among hospice enrollees, we examined racial/ethnic differences in hospice use patterns, including length of hospice enrollment and disenrollment rate.

Results: The mean number of care transitions within the last six months of life was 2.9 transitions (standard deviation [SD] = 2.7) for whites, 3.4 transitions (SD = 3.2) for African Americans, 2.8 transitions (SD = 3.0) for Hispanics, and 2.4 transitions (SD = 2.7) for Asian Americans. After adjusting for age and sex, having at least four transitions was significantly more common for African Americans (39.2%; 95% confidence interval [CI]: 38.8–39.6%) compared with whites (32.5%, 95% CI: 32.3–32.6%), and less common among Hispanics (31.2%, 95% CI: 30.4–32.0%), and Asian Americans (26.5%, 95% CI: 25.5–27.5%). Having no care transition was significantly more common for Asian Americans (33.0%, 95% CI: 32.0–34.1%) and Hispanics (28.8%, 95% CI: 28.0–29.6%), compared with African Americans (19.2%, 95% CI: 18.9–19.5%) and whites (18.9%, 95% CI: 18.8–19.0%). Among hospice users, whites, African Americans, and Hispanics had similar length of hospice enrollment, which was significantly longer than that of Asian Americans. Nonwhite patients were significantly more likely than white patients to experience hospice disenrollment.

Conclusions: Racial/ethnic differences in patterns of end-of-life care are marked. Future studies to understand why such patterns exist are warranted.

Background: To enhance the quality of hospice care and to facilitate consumers’ choices, the Centers for Medicare and Medicaid Services (CMS) began the Hospice Quality Reporting Program, in which CMS posted the quality measures of participating hospices on its reporting website, Hospice Compare. Little is known about the participation rate and the types of nonparticipating hospices.

Objective: To examine the factors associated with hospices’ nonparticipation in Hospice Compare. Research Design: We analyzed data from the CMS 2016 Hospice Compare. “Nonparticipants” were those who did not submit any quality measure. With the data of the Provider of Service file, the Healthcare Cost Report Information System, and the Area Health Resources File, multivariate logistic regressions estimated the association between nonparticipants and hospice and market characteristics, including ownership, size, nurse staffing ratio, and market competition intensity.

Results: Among the 4123 certified hospices subject to penalty from nonparticipation, 259 did not participate in Hospice Compare. California, New Mexico, Texas, and Wyoming had participation rates lower than 80%. Hospices that were for-profit, had no accreditation, had few nurses per patient day, provided no inpatient care, and were located in competitive markets were less likely to participate than other hospices.

Conclusions: Hospice Compare successfully motivated hospice in participating in the quality report program in most of states. For-profit hospices, hospices with less quality, and hospices located in competitive markets were less likely to participate. Further research is warranted to examine the quality of these nonparticipants, especially in the 4 states with a lower participation rate.

Objective: To examine whether regional practice patterns impact racial/ethnic differences in intensity of end‐of‐life care for cancer decedents. Data Sources The linked Surveillance, Epidemiology, and End Results (SEER)‐Medicare database.

Study Design: We classified hospital referral regions (HRRs) based on mean 6‐month end‐of‐life care expenditures, which represented regional practice patterns. Using hierarchical generalized linear models, we examined racial/ethnic differences in the intensity of end‐of‐life care across levels of HRR expenditures.

Principal Findings: There was greater variation in intensity of end‐of‐life care among Hispanics, Asians, and whites in high‐expenditure HRRs than in low‐expenditure HRRs. Conclusions Local practice patterns may influence racial/ethnic differences in end‐of‐life care.

This study examines whether truth-telling in the form of honest reporting is associated with cognitive moral development. Conventional agency theory assumes that people are self-interested and willing to tell a lie to increase their personal payoffs, while recent empirical evidence shows that some people give up monetary rewards to tell the truth (e.g., Evans et al., Account Rev 76:537–559, 2001). The social psychology literature suggests that cognitive moral development influences individuals’ ethical decisions. We carried out an experiment whereby participants submitted managerial reports in which truth-telling decreased their monetary payoff. Despite the fact that their decisions were not subject to monitoring, auditing, or reputation effects, some participants reported honestly or partially honestly. We find the relationship between honest reporting and cognitive moral development to be both positive and linear. Compared with those at lower stages of cognitive moral development, participants at higher stages of cognitive moral development were more likely to submit an honest report and give up potential monetary gains from lying. We further examine the economic impact of honest reporting on the firm’s profit. With the assumption of self-interest and profit maximization, Antle and Eppen (Manag Sci 31:163–174, 1985) suggest that a contract with a hurdle-rate feature reduces managers’ information rent. We find that in comparison with the expected outcome of a hurdle contract, the firm can yield higher profits with a trust contract by hiring managers with a P-score higher than 16.67.

Hospice use is expected to decrease end-of-life expenditures, yet evidence for its financial impact remains inconclusive. One potential explanation is that the use of hospice may produce differential costsavings effects by region because of geographic variation in end-of-life spending patterns. We examined 103,745 elderly Medicare fee-for-service beneficiaries in the Surveillance, Epidemiology, and End Results Program Medicare database who died from cancer in 2004–11. We created quintiles by the adjusted mean end-of-life expenditures per hospital referral region (HRR), and we examined HRR-level variation in the association between length of hospice service and expenditures across quintiles. Longer periods of hospice service were associated with decreased end-of-life expenditures for patients residing in regions with high average expenditures but not for those in regions with low average expenditures. Hospice use accounted for 8 percent of the expenditure variation between the highest and the lowest spending quintiles, which demonstrates the powers and limitations of hospice use for saving on costs.

Objectives: To examine the association between time since cancer diagnosis and health-related quality of life (HRQOL) among cancer survivors in remission.

Methods: Analyzing data from 3,610 cancer survivors and 59,539 individuals without cancer in the Medical Expenditure Panel Survey, we examined the relationship between time since cancer diagnosis and HRQOL, taking remission status into account and controlling for patients’ demographic characteristics and comorbidities. HRQOL measurements included the six-dimensional health state short form (derived from 36-item short form health survey) (SF-6D) utility scores, the physical component summary score, and the mental component summary score.

Results: The relationship between time since cancer diagnosis and HRQOL varied substantially across cancer types. Compared with individuals without cancer, survivors of breast, prostate, or poor-prognosis cancer had statistically lower SF-6D scores within 2 years of diagnosis (−0.044, −0.062, and −0.088, respectively). Breast cancer survivors had SF-6D scores similar to those of individuals without cancer after 2 years, as did patients with poor-prognosis cancer after 5 years. Nevertheless, even after a period of 10 years, survivors of prostate or cervical cancer had a lower level of SF-6D scores (−0.027 and −0.042, respectively). The comparisons of physical health between cancer survivors and individuals without cancer were similar to those of SF-6D. In contrast, most cancer survivors did not experience poorer mental health; survivors of prostate or cervical cancer, however, had lower mental component summary scores after 10 years of diagnosis.

Conclusions: The level of HRQOL among cancer survivors depends on time since cancer diagnosis and cancer type. Some cancer survivors have lower HRQOL after a decade of diagnosis, even in remission.

This study aims to understand how healthcare organizations adapted performancebased compensation for their executives in response to a quality improvement initiative. In 2010, the Ontario Government in Canada enacted the Excellent Care for All Act 2010 (ECFAA), which requires hospitals to prepare their Quality Improvement Plans (QIPs) and prioritize quality indicators to measure performance; furthermore, the ECFAA requires hospitals to link healthcare executive compensation to QIP performance measures. In analyzing the structure of executive performance pay in 119 hospitals’ 2012/13 QIPs, we find that hospitals employ an average of 5.59 indicators related to the quality attributes of safety (1.79), effectiveness (0.96), access (1.03), patient-centred (1.01), and integrated (0.62) in rewarding executives while they use an average of ten indicators to evaluate performance in quality improvement. We also find that the measures used in determining executive performance pay are high-priority indicators in hospitals’ QIPs. These findings suggest that hospitals link their executive performance pay to their high-priority goals in quality improvement. Most hospitals use the identical set of indicators with equal weights and apply the identical at-risk percentages in determining the performance pay for all executives. The average at-risk pay for CEOs and other executives is 6.10% and 4.25%, respectively, of their base salary. We find that 62 hospitals allow partial performance pay for partial achievement of QIP performance targets to recognize executives’ efforts even though QIP targets are not met. Our study suggests that hospitals align measures used for evaluating quality improvement performance with indicators used for rewarding executives.

Capacity decisions involve trade‐offs between the cost of capacity and the opportunity costs of lost sales. Accounting researchers posit that accounting performance provides sufficient information about these trade‐offs and thus can be used to formulate simple rules to assist capacity decisions. Empirical research has not examined the role of accounting information in capacity investment decisions at the department level in a multiproduct firm in the presence of social costs. Empirical analyses using department‐level data from California hospitals for the period 1998–2005 show that hospitals are more likely to make capacity investments in departments with high accounting performance. However, in the presence of demand variability, the association between accounting performance and capacity investment is attenuated because of the resulting increase in noise in accounting performance measures. Thus, the weight on accounting performance as a decision tool for capital investments reduces when there is demand variability. Another factor that reduces the weight on accounting performance is capacity utilization. Higher capacity utilization can lead to turning away or rerouting of patients to other hospitals and negatively impacts reputation and quality of care, which increases the hospital’s social costs. Hence, hospitals do not require high accounting performance before investing in a department with high capacity utilization. This empirical evidence of the role of accounting performance in capacity investment decisions fills a gap in the capacity investment literature and furthers our understanding of the interactions between accounting performance and the operational determinants of firms’ capacity investment behavior.

Facing escalating health care expenditures, the governments of countries with national health insurance programs are trying to control or even to reduce health care utilization. Little research has examined the effects of decreased health care utilization on health outcomes. Applying a natural experiment design to the Taiwan population between 2000 and 2004, which includes the 2003 SARS epidemic when an average 20% decline in health care utilization occurred, this study examines the association between a decline in health care utilization and health outcomes measured by cause-specific mortality rates. We analyse the monthly mortality rates caused by infectious diseases, cancer, diabetes mellitus, nervous system diseases, cerebrovascular diseases, heart and other vascular diseases, respiratory system diseases, digestive system diseases, genitourinary system diseases and accidents. Models control for age, sex, month and year effects. Results show the heterogeneous effect of reduced health care utilization on health outcomes. Patients with diabetes mellitus or cerebrovascular diseases are vulnerable to short-term reductions in health care; compared with the non-SARS period, mortality caused by diabetes mellitus and cerebrovascular diseases significantly increased during the SARS epidemic by 8.4% and 6.2%, respectively. No significant change in mortality rates caused by the other diseases or accidents is found. This study suggests that governments of countries where health care utilization and spending are similar to or inferior to those in Taiwan should carefully evaluate the impact of policies that attempt to reduce health care utilization. Furthermore, when an area encounters an epidemic, governments should be aware of the negative consequences of voluntary restraints on access to health care that accompany decreases in utilization.

This study examines the association between when an airline sells its passenger seats and the pricing method (marginal cost or full cost) it employs. Prior literature suggests that when firms are able to change prices during the selling period, the optimality of full cost pricing or marginal cost pricing depends on when demand information is revealed during the period between capacity commitment decisions and time of sale. Full cost‐based pricing is appropriate in determining capacity commitment and prices simultaneously, while marginal cost provides more relevant information for pricing when capacity has been committed. Using the price and cost data from a sample of four U.S. domestic airlines, we find that full cost explains price variations of first‐day sales robustly. The adjusted R2 of the marginal cost pricing model is larger in the sample of sales two days prior to departure than in the sample of first‐day sales. In the analysis of the sample of sales two days prior to departure, we find that, based on the adjusted R2 of the full cost pricing and marginal cost pricing models, the explanatory power of marginal cost pricing is relatively weaker than full cost pricing. Our results document the use of different cost information along the dynamic change of price and provide implications in understanding the role of cost information in setting prices.

Accounting research raises the concern that firms in the health care and defence contracting industries, when facing a dual payment system with both cost-based and fixed-rate payments, have an incentive to reallocate overhead costs through increasing inputs used in cost-based operations. However, prior literature reports contradictory empirical evidence regarding such real activity manipulation. Drawing on the institutional perspective, we hypothesise that firms’ market power and interorganisational dependence affect their cost-management strategies and choice of overhead allocation in response to dual payment systems. Analysing the data of California hospitals from 1980 to 1991, we find that when facing a dual payment system, dominant (strong market position) hospitals adopt a cost-revenue-enhancing strategy, increasing direct costs for cost-based services without containing costs in fixed-rate services. In contrast, nondominant hospitals choose a cost-reduction strategy and improve operation efficiency on fixed-rate services. We also find that nondominant hospitals shift more overhead costs away from fixed-rate services to cost-based services by reclassifying the allocation bases across services; combining this cost shifting with the cost-reduction strategy, nondominant hospitals demonstrate the compliance with the regulation expectation of cost containment.

Background: Survival in hepatocellular carcinoma (HCC) is lower in the USA than in Taiwan. Little is known about the extent to which differences in stage at diagnosis and treatment contribute to this difference. We examined treatment patterns and survival in HCC and analyzed factors driving the difference.

Methods: Using a uniform methodology, we identified patients aged 66 years and older with newly diagnosed HCC between 2004 and 2011 in the USA and Taiwan. We compared treatment within 6 months after HCC diagnosis and 2-year stage-specific survival between the two countries.

Results: Compared with patients in Taiwan (n = 32,987), patients in the USA (n = 7,003) were less likely to be diagnosed as stage IA (4% vs 8%) and II (13% vs 22%), or receive cancer-directed treatments (41% vs 58%; all p < .001). Stage-specific 2-year survival rates were lower in the USA than in Taiwan (stage IA: 57% vs 77%; stage IB: 38% vs 63%; stage II: 40% vs 57%, stage III: 14% vs 18%; stage IV: 4% vs 5%, respectively; all p < .001 except p = .018 for stage IV). Differences in age and sex (combined), stage, and receipt of treatment accounted for 3.8%, 17.0%, and 16.8% of the survival difference, respectively, leaving 62.5% unexplained.

Conclusions: Differential stage at diagnosis and treatment were substantially associated with the survival difference, but approximately two-thirds of the difference remained unexplained. Identifying the main drivers of the difference could help improve HCC survival in the USA.