Operational and incentive issues in health care delivery systems

The dissertation consists of three self-contained but related papers on operational and incentive issues in health care delivery systems.;Managing the delivery of dialysis therapy. Motivated by the exceptionally high mortality statistics of dialysis patients and the ongoing debate about the adequacy of the current reimbursement for dialysis in the United States, we pursue a detailed analysis of the dialysis delivery system. The analysis is based on a multi-class fluid model for a dialysis facility, which combines a pharmacokinetics model of dialysis and an empirically validated model of dialysis-specific mortality. Assuming that the not-for-profit facility operates under budget and capacity constraints, our analysis determines the main factors that affect the delivery of dialysis. Numerical results, representative of the dialysis environment in the US, demonstrate the accuracy of the model and provide concrete insights about the operations of the dialysis facility.;Outcomes-based reimbursement in health care. We consider a two-party health care delivery system in which a purchaser of some medical service delegates clinical decisions to an independent provider. Patients arrive exogenously, receive periodic outpatient clinical services from the provider, suffer complications that require inpatient services, and eventually leave the system due to death. The provider incurs the cost associated with the outpatient services, while the purchaser incurs the cost of inpatient services and reimburses the provider for his services using an outcomes-based scheme. We use a dynamic principal-agent model to develop the "optimal" financial arrangement that generates the most efficient health outcomes.;Financial incentives in dialysis reimbursement. We propose a numerical framework for quantifying the effect of financial incentives on the intensity of dialysis therapy delivered by a for-profit dialysis provider to a heterogeneous ESRD patient population. Three types of reimbursement mechanisms are compared: the fee-for-service payment system currently used by Medicare to reimburse dialysis providers, an unadjusted capitated payment system that holds the providers financially responsible for both dialysis and dialysis-related hospitalization expenses, and an adjusted capitated payment system that further takes into account variation in patient characteristics and the misalignment of incentives between Medicare and dialysis providers.