Award Date


Degree Type


Degree Name

Doctor of Philosophy (PhD)


Environmental and Occupational Health

First Committee Member

Josué Epané

Second Committee Member

Christopher Cochran

Third Committee Member

Jay Shen

Fourth Committee Member

Xan Goodman

Number of Pages



The Patient Protection and Affordable Care Act present some threats and opportunities to many hospitals across the USA. Under the Value-Based Purchasing Program, acute care hospitals' rewards are tied to incentive payments for the quality of care provided in the inpatient hospital. In the last 20 years, growing research has examined the effects of the quality of care on the financial performance of hospitals. There is a gap in the literature, particularly exploring the relationship between quality and hospital financial performance using national samples. This dissertation investigates the association between patients' experience of care, 30-day readmission rates, and case-mix-index (CMI) and hospital financial performance. We carried out a meta-analysis exploring the impact of readmission on financial performance. Additionally, using a national sample of acute care hospitals operating in the US between 2008 and 2019, we conducted a longitudinal panel design study with hospital and year fixed effect. We investigated the association between quality (CMI, HCHAP composite measures, and 30-days readmission rates for Acute Myocardial Infarction (AMI), Heart Failure (HF), and Pneumonia (PN)) and financial performance as measured by the operating revenue, operating cost, operating margin, and total margin. For the meta-analysis, we simulated 100 000 sample draws from the modeled distribution for each related analysis for each readmission category at the same time and recorded the mean and 95 percent confidence interval obtained from the distribution of those 100000 weighted averages. Following the Monte-Carlo simulations, the mean cost of 30-days readmission for all conditions simulated at $16,037.08 (95% CI, $15,196.01 – $16,870.06). The mean cost of 30-days readmission for AMI is $6,852.97 (95% CI, $6,684.44 – $7,021.08). The mean cost of 30-days readmission for HF is estimated at $9,817.42 (95% CI, $9,575.82 – iv $10,060.43). The mean cost of 30-days readmission for Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) is simulated at $21,346.50 (95% CI, $20,818.14- $21,871.85). Results of the longitudinal study show that higher composite HCHAP scores when studied separately for Nurse communication, Doctor's communication, care transition, Willingness to recommend, and HCHAP Star rating did not significantly impact financial performance. The composite measure for high Discharge Information scores did not increase operating revenues or costs per adjusted patient day and operating margin, but marginally increased the bottom line (total margin) (β =0.007, p < 0.061). We also found that reduced 30-day readmissions for AMI, HF and PN did not improve financial performance. Finally, we found that hospitals with a higher CMI had increased patient revenues (β =757.878, p< 0.000) and costs per adjusted patient day (β =643.108, p< 0.000) and increased profitability measured as operating margin and total margin. However, the higher operating costs attributed to sicker populations were offset by increased patient revenues, resulting in a significant increase in operating margin (β = 3.200, p < 0.002) and a marginally significant increase in the total margin (β = 2.068, p< 0.017). These findings suggest a business case for hospitals treating severely ill patients, those with resource intensive prognosis, requiring difficult treatment, and in need of intervention. These findings also suggest that focusing on individual quality measures may not present the true impact of quality financial performance may be better captured with more global quality measures.


Case Mix Index; Financial Performance; Perception of Care; Readmissions


Health and Medical Administration | Public Health | Public Policy

File Format


File Size

1701 KB

Degree Grantor

University of Nevada, Las Vegas




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