Effective crisis decision-making

When an organisation's reputation is at stake, crisis decision-making (CDM) is challenging and prone to failure. Most CDM schemes are strong at certain aspects of the overall CDM process, but almost none are strong at all of them. This paper defines criteria for good CDM schemes, analyses common approaches and introduces an alternative, stakeholder-driven scheme. Focusing on the most important stakeholders and directing any actions to preserve the relationships with them is crucial. When doing so, the interdependencies between the stakeholders must be identified and considered. Without knowledge of the sometimes less than obvious links, wellmeaning actions can cause adverse effects, so a cross-check for the impacts of potential options is recommended before making the final decision. The paper also gives recommendations on how to implement these steps at any organisation in order to enhance the quality of CDM and thus protect the organisation's reputation.

How ACA Is Forcing a Technology Revolution

The Affordable Care Act (ACA) has magnified the problem of short-sighted human resource (HR) software purchases that reflect a siloed mindset about HR technology investment. This article outlines the problem with the siloed approach and the many advantages offered by an HR technology revolution. The author reviews best practices to consider, whether from the perspective of a consultant or that of an HR professional building a case internally for integration. When investment in HR technology is based on how the technology can help employees make better decisions because of greater access to accurate data, the ripple effects of improved decision making translate into real savings.

Decision-making in crisis: Applying a healthcare triage methodology to business continuity management

The concept of triage in healthcare has been around for centuries and continues to be applied today so that scarce resources are allocated according to need. A business impact analysis (BIA) is a form of triage in that it identifies which processes are most critical, which to address first and how to allocate limited resources. On its own, however, the BIA provides only a roadmap of the impacts and interdependencies of an event. When disaster strikes, organisational decision-makers often face difficult decisions with regard to allocating limited resources between multiple 'mission-critical' functions. Applying the concept of triage to business continuity provides those decision-makers navigating a rapidly evolving and unpredictable event with a path that protects the fundamental priorities of the organisation. A business triage methodology aids decision-makers in times of crisis by providing a simplified framework for decision-making based on objective, evidence-based criteria, which is universally accepted and understood. When disaster strikes, the survival of the organisation depends on critical decision-making and quick actions to stabilise the incident. This paper argues that organisations need to supplement BIA processes with a decision-making triage methodology that can be quickly applied during the chaos of an actual event.

Equipping an urban hospital police and security team with Narcan: part two

In their article in the last issue of the Journal, the authors reported on their health system's decision to equip their security officers with Narcan, the nasal-spray form of naloxone, and train them to use the drug to revive patients and non-patients overdosed with heroin or other life-threatening opioids. The decision, they said, was prompted with an increase in individ- uals who may come to the hospital ' 32 buildings and over 130 offsitefa- cilities to "shoot up" themselves. In this follow-up report, they describe what has happened in the seven months since the policy was begun-- how many times Narcan was utilized; what happened during such incidents; lessons learned; and how comfortable security officers are with this new re- sponsibility.

Evidence for Busines Intelligence in Health Care: A Literature Review

This paper outlines a systematic literature review undertaken to establish current evidence regarding the impact of Business Intelligence (BI) on health system decision making and organizational performance. The review also examined BI implementation factors contributing to these constructs. Following the systematic review, inductive content analysis was used to categorize themes within the eight articles identified. This study demonstrated there is little evidence based literature focused on BI impact on organizational decision making and performance within health care. There was evidence found that BI does improve decision making. Implementation success was found to be dependent on several factors, many of which relate to broader organizational culture and readiness.

International Nursing: How Much Power Do Nurse Managers Have?

This study was conducted to explore issues of nurse managers' power and empowerment. Data were collected from nurse managers by way of a questionnaire consisting of background factors, work-related questions, and power-related questions at the unit and organization levels. The degree of empowerment was evaluated using 2 established instruments (CWEQ-II and Work Empowerment Questionnaire). The overall level of managers' personal power within their own units was relatively high. Nurse managers' perception of their power at an organizational level was found to be at a moderate level. Several factors related to an individual's professional background were correlated to power issues, both at the unit and organizational levels. Structural and psychological empowerment correlated with the overall level of power at a unit level and the overall level of power at an organizational level. Nurse managers self-reported their own general power at a unit level as high, which offers them possibilities to lead the development of nursing care in their units. Organizations may benefit more from nurse managers' leadership by more fully integrating them in the development processes of the entire organization.

Determining the appropriate strategies for emergency planning through AHP-SWOT

During an unexpected incident, companies should demonstrate appropriate behaviour based on predetermined and rehearsed emergency strategies. This paper describes how to select the proper strategies for emergency situations via means of the AHP-SWOT tool, where the initial SWOT analysis is conducted for the emergency management system, and the final strategies are selected via the analytic hierarchy process (AHP). Alternative response strategies comprise internal, shared and external responses. Most of the scenarios investigated for this study demanded a shared response. These findings highlight the importance of mutual aid agreements, cooperative exercises and the improvement of communication systems. Organisations can take advantage of integrated approaches to select the best strategies and tactics for normal situations in general and emergency situations in particular.

Involving law enforcement and emergency management officials in exercises

This article reveals the benefits of having public sector participation in your exercises. It also outlines simple tips to having successful business continuity exercises for your organisation.

Shifting Paradigms in Canadian Healthcare to Support the Scale and Spread of Innovation

Health systems and healthcare organizations across Canada have identified the need for innovation to transform healthcare by creating the conditions for successful, scalable and impactful system transformation. Meeting these goals requires adopting new leadership paradigms to shape and design policy frameworks, business models, technical structures and funding approaches. In order to scale innovation and achieve system-wide impact, system leaders will need to create a culture that supports innovation and transformational change.

Toward a collaborative model of pandemic preparedness and response: Taiwan's changing approach to pandemics

BACKGROUND

Over time, as newly emerging infectious diseases have become increasingly common and more easily spread, it has become clear that traditional response mechanisms have proven inadequate to the task of prevention and control.

PURPOSE

To explore whether enhanced cooperation with local government and community institutions can effectively supplement traditional state-centric public health epidemic responses.

METHODS

Drawing on Taiwan as a case study, we assess the role of the whole-of-society approach to epidemic response as arises from the collaborative governance literature. The approach calls for enhanced cooperation, trust building, resource sharing and consensus-oriented decision making among multiple levels of government, business, non-profits, and the public in general.

RESULTS

The Taiwan case illustrates the benefits of the whole-of-society approach. Enhanced cooperation between state, local government and non-state institutions, particularly neighborhood committees, has resulted in a strengthened, holistic epidemic preparedness and response infrastructure.

CONCLUSION

The Taiwan case provides evidence that by implementing the whole-of-society approach to pandemic preparedness and response governments can enhance their ability to manage future outbreaks. We recommend that governments beyond Taiwan's borders seriously consider adopting this approach.

Regionalization of health services in Newfoundland and Labrador: perceptions of the planning, implementation and consequences of regional governance

Objectives

To describe the context and key drivers for regionalization of one provincial health care system in Canada; to document the original expectations of regionalization on governance and the extent to which these expectations were met; to identify the perceived successes and weaknesses of the process; and to examine the key issues and concerns that warrant further consideration and action in the future.

Methods

Forty-five CEO/senior administrator or senior health department officials in the period 1993-2001 were invited to participate, of whom 35 were interviewed (67% of senior health officials and 85% of CEOs/ senior administrators).

Results

For the most part, key informants felt that expectations of reform with respect to reduction in the number of boards and integration of services under each board's mandate did occur. However, ongoing financial restraint, failure to include the full range of health services under the regional board mandate (including physician and pharmaceutical services), uncertainty regarding the level of authority the regional boards had for decision-making, and unclear accountability mechanisms between the regional boards and the provincial Ministry of Health limited the extent to which broader expectations related to development of a population health focus, and improved continuity of care for individuals and families was achieved.

Conclusions

Implications for policy-makers were identified in four main areas: alignment between health policy goals and the governance structure; clarification of authority and accountability relationships; clarification of roles and responsibilities among all key actors; and strengthening of mechanisms that support accountability.

Rationalizing resources a framework and a process

To meet the demands of population health and value-based care, healthcare organizations may soon be compelled to take steps to rationalize their service and resource offerings.

Joint Venture Health Plans May Give ACOs a Run for Their Money

Joint venture plans are starting to demonstrate their ability to implement clinical management and financial management reforms. A JV health plan replaces the offloading of financial risk by health plans to ill-equipped providers with an executive-level cost management committee stated jointly by the hospital and payer.

School Nurses’ Perceptions of Empowerment and Autonomy

The purpose of this study was to explore Kanter’s Theory of Structural Power in Organizations, using school nurses and to answer the research question of whether there is a relationship between empowerment and autonomy in school nurses. This study found a positive relationship between the nurses’ perceptions of empowerment and autonomy. The school nurses surveyed perceived themselves to have a high degree of autonomy and a moderate degree of empowerment, and they reported that their access to informal power structures was higher than their access to formal power structures in their school systems. School nurses can benefit by understanding factors that can increase their empowerment in the workplace. They need to understand the organizational structure of their workplace to increase their effectiveness and job satisfaction.

Challenges to polycentric governance of an international development project tackling land degradation in Swaziland

To effectively address the drivers and impacts of land degradation requires polycentric governance systems that facilitate international development projects (IDPs). This paper analyses an IDP aiming to reduce land degradation in Swaziland. A longitudinal-style qualitative approach draws on repeat household surveys, semi-structured interviews and focus groups. We aim to identify the changes that have taken place since the departure of the IDP funders, and the subsequent dynamics between stakeholders. We: (1) chart the evolution of the institutional structures and processes of the IDP; and (2) assess community perceptions of IDP outcomes. Lack of meaningful participation at various stages of the PMC caused the project to lose momentum following the departure of the funders. We discuss these findings in relation to a polycentric approach, and identify how multi-stakeholder IDP can be facilitated as part of wider polycentric governance approaches to inform policies to combat land degradation within Swaziland and more widely.

Use of the 'Accountability for Reasonableness' Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.

CHOOSING THE RIGHT PERFORMANCE MANAGEMENT SYSTEM FOR YOUR ACO

Measurement of performance against cost and quality benchmarks represents a defining principle of accountable care organizations (ACOs). However, in order to successfully improve population health and patient satisfaction while controlling costs - in other words, to achieve the Triple Aim - ACOs require more than performance measurement.

Developing Governance Structures in Health Care System Consolidation: A Framework for Nurse Leaders

Given the acceleration and increasing complexity of integrative care models across health systems, the question how governance and management structure(s) should be operationalized and evolved to achieve peak system performance is paramount. In a recent evaluation of partnerships with the University of Kentucky HealthCare (UK HealthCare), the conceptualization of the integration management model was explored. It was recognized that nursing leadership, governance structure, and relationships are vital for successful movement and migration of appropriate care models. In this case, the evolving governance models and the forecasted impact on models of care delivery were carefully considered. This included the potential impact on nursing practice. As the model was developed, a conceptual framework was utilized to examine potential variant relationship arrangements and to provide organization to key constructs. Utilization of a blueprint to optimize decision making and provide a replicable approach was essential to management of the integration philosophy.

Equipping an urban hospital police and security team with Narcan

Narcan, the nasal-spray form of naloxone, has been approved by the FDA as an easy-to-use version of a drug for saving lives of people who have overdosed on opioids--heroin or prescription painkillers. Communities across the US have been equipping first responders and police with the spray. Now, as the increase in overdose deaths has spread to hospitals, those facilities will have to decide whether their police/security officers should be equipped with. naloxone and trained in its use. In this article, the authors relate their health system's decision, how it was reached, and how it has been implemented.

A NEW ECOLOGY IN HEALTH CARE

Providers and practices need to start making changes now to prepare for a new way of doing business and caring for patients; and physician leaders need to lead the charge.

MISSION, VISION AND VALUES STATEMENTS: THE PHYSICIAN LEADER'S ROLE

Take an in-depth look at mission, vision and values statements, and see why it's important that they be thoughtfully constructed.

Making the Most of Technology

Doing technology well involves negotiating multiple hurdles, from skeptical boards to lack of national direction, heard HSJ's latest roundtable panel. Ingrid Torjesen reports on the event.

Commitment to and preparedness for sustainable supply chain management in the oil and gas industry

Our current dependency on the oil and gas (O&G) industry for economic development and social activities necessitates research into the sustainability of the industry's supply chains. At present, studies on sustainable supply chain management (SSCM) practices in the industry do not include firm-internal factors that affect the sustainability strategies employed by different functional areas of its supply chains. Our study aims to address this gap by identifying the relevant internal factors and exploring their relationship with SSCM strategies. Specifically, we discuss the commitment to and preparedness for sustainable practices of companies that operate in upstream and downstream O&G supply chain. We study the impact of these factors on their sustainability strategies of four key supply chain functions: supplier management, production management, product stewardship and logistics management. The analyses of data collected through a survey among 81 companies show that management preparedness may enhance sustainable supply chain strategies in the O&G industry more than commitment does. Among the preparedness measures, management of supply chain operational risks is found to be vital to the sustainability of all supply chain functions except for production management practices. The findings also highlight the central importance of supplier and logistics management to the achievement of sustainable O&G supply chains. Companies must also develop an organizational culture that encourages, for example, team collaboration and proactive behaviour to finding innovative sustainability solutions in order to translate commitment to sustainable practices into actions that can produce actual difference to their SSCM practices.

Where is the pilot? The changing shapes of governance in the European hospital sector

Hospital governance refers to the complex of checks and balances that determine how decisions are made within the top structures of hospitals. This article explores the essentials of the concept by analysing the root notion of governance and comparing it with applications in other sectors. Recent developments that put pressure on the decision-making system within hospitals are outlined. Examples from the UK, France and the Netherlands are presented.

Based on an evaluation of the current state of affairs, a research framework is developed, focusing on the determinants of governance configurations within the national healthcare systems and the wider legal and socio-economic context, as well as on the impact of governance configurations on the efficiency of the governing bodies and overall hospital performance.

The article concludes with a preview of the European Hospital Governance Project, which follows the outlines of the described research framework. New techniques of data mining that are used in this project are explained by means of a real data example.

Joining forces, joining futures: Hospice at the crossroads

Faced with health-policy changes, increased competition, and limited funding, hospices must either find more efficient ways to provide end-of-life care or risk organizational demise. Increasingly, hospices are re-evaluating their organizations to stretch resources and remain viable. Prevalent restructuring options for addressing environmental pressures are integration, alliance, and collaboration with other organizations. This study examines the restructuring phenomenon by evaluating trends among nonprofit hospices in six states. The study identifies demographic characteristics predictive of organizational decisions to join forces, and it examines the dominant political and economic reasons that propel or impede restructuring decisions. In addition, the study evaluates the results of restructuring actions.

Evaluating Transformational Leadership Skills of Hospice Executives

Health care is a rapidly changing environment requiring a high level of leadership skills by executive level personnel. The hospice industry is experiencing the same rapid changes; however, the changes have been experienced over the brief span of 25 years. Highly skilled hospice executives are a necessity for the growth and long-term survival of hospice care. This descriptive study was conducted to evaluate the leadership skills of hospice executives. The study population consisted of hospice executives who were members of the state hospice organization in Ohio and/or licensed by the state (88 hospice providers). Three questionnaires were utilized for collecting data. These questionnaires collected data on transformational leadership skills of participants, participants’ personal demographics, and their employer’s organizational demographics. Forty-seven hospice executives responded (53%). Key findings reported were high levels of transformational leadership skills (mean, 3.39), increased use of laissez-faire skills with years of hospice experience ( P = .57), and positive reward being a frequent leadership technique utilized (mean, 3.29). In addition, this was the first study of leadership skills of hospice executives and the first formal collection of personal demographic data about hospice executives.

Data monitoring in randomized controlled trials: surveys of recent practice and policies

Background Data Monitoring Committees (DMCs) are increasingly involved in the conduct of randomized controlled trials, but there is little documented evidence of what they do. Three interlinked surveys were carried out as part of the DAMOCLES project to explore recent and current DMC practice and policy.

Methods 1) A questionnaire about DMC practice was sent to sample of 45 authors of trials published in selected journals in 2000. The sample was stratified by centre (single/multiple), disease area, and presence of DMC. 2) A sample of investigators in trials ongoing in the United Kingdom in 2001–02 was also sent a questionnaire about DMC practice. The sample was drawn from trials funded by the Medical Research Council, the United Kingdom Department of Health's Health Technology Assessment Programme, and a local and a multicentre research ethics committee. The sample was additionally stratified by funder (public/industry), centre (single/ multiple), and disease area. 3) A sample of major organisations involved in randomised controlled trials was sent a questionnaire about DMC policies.

Results Information about DMC practice from the first survey was obtained from 31 trials (69%), of which four had a DMC. Information about DMC practice from the second survey was obtained about 36 trials (90%), of which 20 had a DMC. Information about DMC policy from the third survey was obtained from 25 out of 25 organisations. There was general agreement about the sorts of trials particularly needing independent DMCs, but there were few uniform approaches to their modes of functioning, and few of the organisations surveyed had developed formal policies. Conclusions The roles of existing DMCs and policies governing DMC functioning vary widely across trials and organisations that sponsor or oversee trials, both within the UK and internationally. These findings reinforce previous calls for development of such policies across a wider range of organisations, better means to monitor their implementation within trials, and wider use of structured “charters”, which set out DMC modus operandi in advance.

Small group processes relevant to data monitoring committees in controlled clinical trials: an overview of reviews

Background The quality of the decisions reached by data monitoring committees (DMCs) is crucial. The aim of this paper is to identify factors that may make errors more or less likely in small, task-oriented, decision-making expert groups and to consider the implications of these factors for data monitoring committees.

Methods A systematic overview was carried out of reviews of empirical studies of small group processes and decision errors in small, task-oriented decision-making groups in laboratory or real-world settings, published between 1950 and 2002 (n = 57 included reviews).

Results These reviews suggest that a number of factors may increase the likelihood that small groups will make poor and potentially erroneous decisions. The most important of these, in terms of empirical support, are: biased or overly directive leadership, expression of a limited range of opinions during group discussion, poor procedures for identifying or appraising the available information, and presentation of the available information in a way that is likely to result in biased perception of it.

Conclusions The main implications for DMCs relate to membership, the role of the chairperson, the information provided for DMCs and training for DMC members. Selection methods that encourage a degree of diversity within the DMC are recommended. Chairs of DMCs should be experienced members, who have the skills to facilitate a discussion, can manage conflict effectively and can be impartial. Adherence to a prespecified analysis plan is recommended to reduce the risk of error associated with strong evidence or excess information. Training in the use of methodical decision-making procedures, education about the factors that influence decision quality and an opportunity to participate in mock DMC discussions may be of benefit for new members.

Pay Attention to Details when Selling Your Practice

The healthcare industry is in a state of confusion and has been for the past 15 years. Physicians are faced with dwindling reimbursement rates, demanding administrative tasks, and changing federal and local rules and regulations. On the flip side, hospitals and healthcare networks are interested in pur- chasing physician practices. Should you consider keeping the status quo, turning over many of the administrative headaches, or just retir- ing all together? As a provider, should you take over or continue a solo practice, join a multispecialty group, or become an employee of a hospital? Buying or selling a practice can be life changing. The process is complex, and involves legal, tax, accounting, valuation, and psychological issues. It takes time and due diligence. It involves an entire team of professionals, which can and should include accountants, lawyers, and consul- tants all of whom specialize in this area. The intent of this article is to establish a starting point on wlhere and how to begin. It addresses major issues that should be considered in the beginning of this complex process. Whether you are a buyer or a seller, you will face many of the same processes and questions. A host of legal and practical issues will confront you, and this article explores your options.

Can I trust them to do everything? The role of distrust in ethics committee consultations for conflict over life-sustaining treatment among Afro-Caribbean patients

BACKGROUND

Distrust in the American healthcare system is common among Afro-Caribbeans but the role of this distrust in conflict over life-sustaining treatment is not well described.

OBJECTIVE

To identify the ways that distrust manifests in ethics committee consultation for conflict over life-sustaining treatment among Afro-Caribbean patients.

METHODS

This was a retrospective cohort study at a large academic hospital of all ethics committee consultations for life-sustaining treatment among Afro-Caribbean patients and their surrogates. We reviewed medical records and identified cases in which ethics consultants described distrust as playing a role in the conflict over life-sustaining treatment.

RESULTS

Of the 169 ethics committee consultation cases for conflict over life-sustaining treatment, 11 (6.5%) involved patients who self-identified as Afro-Caribbean. Distrust played a role in several of these cases, with surrogates of three patients, in particular, illustrating the way that perceived heath disparities, past labelling and concerns about continued maltreatment generated distrust leading to conflict over life-sustaining treatment.

CONCLUSIONS

Exploring issues of distrust may help ethics consultants identify the source of conflict over life-sustaining treatment among Afro-Caribbean patients.

'There's a culture of physician engagement and transparency'

Carl Armato, president and CEO of 14-hospital Novant Health, has worked with the system's employed and affiliated physicians to put them at the center of decisionmaking, a model he says has facilitated a systemwide embrace of electronic health records. Armato, who joined the Winston-Salem, N.C.-based health system Novant in 1998 and has been the top exec since 2012, recently spoke with Modern Healthcare Southern Bureau Chief Dave Barkholz about that physician-administrative partnership, Novant's effort to improve its hospital operations and North Carolina's efforts to provide price transparency for healthcare consumers. This is an edited transcript.

Less Is More in Presenting Quality Information to Consumers

Much effort has been put into improving measures of health care quality. Although early research suggested that consumers made little use of quality reports, most reports were based on nonstandardized measures and were not user friendly. Information presentation approaches, however, will have a significant influence on what information is attended and used. The present research examines whether information presentation methods differentially influence consumers who differ in numeric skills. Results of three studies support the idea that “less is more” when presenting consumers with comparative performance information to make hospital choices. Results were particularly strong for those lower in numeracy, who had higher comprehension and made better choices when the information-presentation format was designed to ease the cognitive burden and highlight the meaning of important information. These findings have important implications for the sponsors of comparative quality reports designed to inform consumer decision making in health care.

Caring Work, Personal Obligation and Collective Responsibility

Studies of workers in health care and the care of older people disclose tensions that emerge partly from their conflicting obligations. They incur some obligations from the personal relationships they have with clients, but these can be at odds with organizational demands and resource constraints. One implication is the need for policies to recognize the importance of allowing workers some discretion in decison making. Another implication may be that sometimes care workers can meet their obligations to clients only by taking collective action.

The Concept of Futility in Health Care Decision Making

Life saving or life sustaining treatment may not be instigated in the clinical setting when such treatment is deemed to be futile and therefore not in the patient’s best interests. The concept of futility, however, is related to many assumptions about quality and quantity of life, and may be relied upon in a manner that is ethically unjustifiable. It is argued that the concept of futility will remain of limited practical use in making decisions based on the best interests principle because it places such high demands on the individual responsible for decision making. This article provides a critical analysis of futility (in the context of the best interests decision-making principle), and proposes an ethically defensible notion of futility.

The Role of the Safety Net in Employer Health Benefit Decisions

The potential for sizable crowd-out of private expenditures by public insurance and delivery programs has been demonstrated. However, there is limited evidence about whether this stems from decisions of employers about their health benefit package or by decisions of workers. This study focuses on the role of public programs on employer decisions to offer insurance and the amount the employer contributes to the premium, using data from a large survey of employers and a database describing community characteristics. The study finds that both public insurance and public delivery programs have a significant effect on employer decisions, but the magnitude of the effect is small. Policies to limit crowd-out should focus on incentives to make continued private insurance purchase attractive to workers rather than incentives to employers.