Abstract
Purpose. The purpose of this study was to examine the impact changes in Medicare policies have on access, utilization, and cost in home health and across the healthcare delivery system. This study examines why Medicare has failed to administer efficient, effective, equitable, and responsible policies, and what alternatives exist utilizing a theory-driven approach to the policy process. Theoretical framework. A conceptual synthesis of Senge's work on Systems Thinking and Fredrickson's New Public Administration movement are utilized to articulate the complexities that exist in healthcare policymaking. This study embraces the concept that our healthcare system is a complex system. Systems analysis is useful in addressing complexity allowing for a rich and diverse set of policy analyses and solutions. Methodology. This study utilized a multiple interrupted time-series design to measure pre- and postreactions to changes in Medicare policies. Utilizing secondary data from the National Claims History, a purposive sample of Medicare beneficiaries who accessed, utilized, and incurred cost in home health, hospitals, and skilled nursing facilities (SNFs) during the time periods of 1967 to 1998 was obtained. T-test of significance and regression were used to analyze the variables access, utilization, and cost and analysis of variance (ANOVA) was used to compare the means of the three healthcare groups to determine if patterns of cost shifting exist. Findings. There is evidence to support significant differences in access, utilization, and cost in home health, SNFs, and hospitals, and there is evidence to support shifting of burdens in access across the healthcare system. However, not all changes in policy caused the expected changes among the variables. In some instances the variables behaved opposite of what was expected in the study. These unexpected findings could be a result of balancing forces within the respective healthcare systems. Conclusions and recommendations. The data do support the general thesis of underlying complexity in the Medicare system and the need for further research. The researcher's overall intent was to raise the level of awareness of the depth, the breadth, and the scope of the problem under study and the need for a theory-driven approach to the policy process that embraces systems thinking and a multiple perspectives approach. It is from this perspective we can promote efficiency, effectiveness, equity, and responsibility in Medicare reimbursement policies.