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Is American health care delivery system heading towards a comprehensive reform?

Initial remarks: ___________________________________ Personal health care delivery system provides Preventive, Acute, Chronic, and End-of-life health care for individuals.

Initial remarks: ___________________________________ Personal health care delivery system provides Preventive, Acute, Chronic, and End-of-life health care for individuals. However, with growing numbers of 'baby boomers', the customers' wants and needs have been shifting to long term care for chronic conditions. Chronic conditions affect almost half of the U.S. population and account for the majority of health care expenditures4.

In addition, 40 million people are uninsured and can't bear rising health care cost and leaving continuous pressure on care providers. As these two problems became systemic (global), there has been a nationwide pressure on adopting "universal care".

On the other hand, there are strong lobbies that resist "radical change with universal coverage" so long the social value of "right to freedom" is strong. Therefore, to establish the "Freedom of rights", we need a reform that creates a "win-win situation" between 'interests groups' - between weaker uninsured and social workers, dissatisfied state government, business firms etc., and ' the pressure groups' - lobbyist who believe in individualism.

A. Problems in current health care delivery system that precipitates need for reform: ______________________________________________________________________ Well-designed and well-run health care delivery is difficult to ensure if Public policy and market forces are not aligned and supported by appropriate IT infrastructure. The current problems in health care systems are summarized as bellow:

1. Organization and Delivery - provision of care: ___________________________________________ o Quality and safety Concern - Lack of 'evidence based quality standards' and Excessive focus on "sick care": _______________________________________________________________________________________________ Tens of thousands of people die5 each year suffer or barely escape from nonfatal injuries from Medical errors including overuse and under use of medications and procedures that a quality care system may prevent. These errors reflect the inability to translate latest best knowledge and new technology into practice safely and appropriately. Moreover, the system is not prepared to adopt upcoming extraordinary technology, because: " Health care providers can not realize what quality is needed; " The support systems needed to comply with safety may be absent; or " Financial incentives may be misaligned.

o Inefficient use of information technology: __________________________________________________ " Less health care dollars to IT - lack of nationwide IT infrastructure that support health care delivery; " As consumers needs have been shifted more to long term care, managing chronic conditions needs well connectivity. A sophisticated IT infrastructure is needed to communicate and coordinate full complement of services for chronic conditions. " Lack of provider specific standalone IT backbone that improves administrative, financial and clinical outcome. More than half of all physicians constitutes 'Small practice physicians' who can not maintain this IT backbone, because the cost of EMRs outweigh their benefits7.

o Cost-benefit trade off - growing systemic concern of unsustainable cost of care. The reasons are: ____________________________________________________________________________________________ " Expensive and emerging new technologies and drugs; " Baby boomers in search of new services with concomitant shortfall in nurse staffing; " Uninsured 40 million -17 of the population has been decreasing, or moving towards larger deductible, HSA or defined contribution because: _________________________________________________________________________________________________________________________________________ " The coverage and community rating has been declining5, and of rising cost; " As firms no more enjoy monopoly in domestic market. Because of antitrust laws, free & uncertain economy, they can not subsidize health benefits any more. " Employees can not sustain defined benefits, because unionization is declined.

o 'Means-tested insurance' like Medicaid and Medicare covering almost 30 of most health care costs, and 100 of prescriptions are provided free to people who have low income or are presented with permanent disabilities. Moreover, people who pay for prescriptions pay only 50 of the health care facility is provided by MCOs. For profit managed care treats health care as 'consumers' commodity' like most general liability insurance (home, automobile), rather than treating it as 'ethical & egalitarian goods'. As a result: ____________________ a) The premium is rising and many are going uninsured; b) A significant and growing number of people cannot obtain health insurance through their employer as employers can not afford the ever-growing costs of benefit plans, or are unable to afford individual coverage. The result is higher deductible, HSA and defined contribution. c) The cost of most medicines is high and U.S. Citizens at times, travel to Canada and Mexico for drugs that are sold at prices far below those in their home areas;

" On the other hand, Medicare that serves 41.7 million of chronically ill people and spends $295 billion yearly face tremendous problem. People face adverse drug event while in 'transition-care' from one provider setting to another. Through QIOs in 53 states, CMS provides technical assistance to nursing homes, hospitals and physicians' offices to improve quality of care, yet the change is reported to be inadequate3. In addition, Medicare has been facing serious financial crisis. " As a result of these flaws, few states have taken serious steps to come out of managed care concept and heading toward 'universal health care coverage' or pay providers through Charity Care scheme.

C. "Possible reform agenda on state governmental level" _____________________________________________________________ In order to achieve truly sustainable health care reform, a country must have a confluence of broad skills to manage its health system. These include financial and human resources as well as logistics, information, and medical and public health expertise. Moreover, the extent of reform is defined by the intensity of the problems and needs felt by different groups of population.

C.1 Choosing a reform agenda from many alternatives: _________________________________________________________

Although the problems in U.S Health Care are widespread, yet it can be resolved. The question is how and when we need to solve what problems. Therefore, before taking initiatives we have to focus on following issues:

. o On what level we do need to reform - State or federal level? o What we need to reform - Financing, administrative or health care delivery (clinical outcome) as separate issue, or take them all together? o What kind reform we do want? ________________________________________________________ " Incremental reforms - that focuses on reducing the number of uninsured by: _______________________________________________________________________ " Employer mandate, " Subsidies, " Means-tested: Medicare & Medicaid,

" Reform that focuses on Financing by: ________________________________________________ " HSAs, " Managed competition " Quality incentives - pay for performance and subsidy for EMRs

" Comprehensive reform-that focuses both on financing, administration and delivery: ______________________________________________ o Individual mandates and subsidies o Single payer universal coverage o Individual Voucher system

Whatever may be the extent of reform, all stakeholder have to agree upon it. The commitment to investment by government and health care providers/organizations are also important issues to be considered.

C.2 Which one is better - Incremental or comprehensive reform? __________________________________________________________

A reform that eliminates inefficiencies in current system and increase coverage without increasing total outlays of Health care dollar is politically viable reform. The problems of quality, access and knowledge-based participatory care became a systemic rather than focal problem all over U.S. Although a lots of 'incremental reform' has been taken so far, none became successful in all these respects except increasing coverage in children insurance and some drug coverage in piecemeal, but at the cost of greater health care spending. Therefore, incremental reforms could not: __________________________________________ o Achieve universal coverage; o Greatly reduce administrative expenses; o Address discontinuities in coverage; and o Increase the cost-effectiveness of care.

On the other hand, although comprehensive reforms need lots of enactments, yet it creates political viability of sustainable benefits.

C.3 Things to remember while considering comprehensive reform: _______________________________________________________

1. Obstacles to Reform7: _______________________________ Satisfaction with status quo: ____________________________ If two-thirds of the public are dissatisfied with the present system, that would leave a sizable minority who do not want any reform and reduce resistance to reform;

Lobby of Single-issue groups: __________________________________ Single-issue constituencies tend to concentrate their lobbying efforts on their particular issues like better coverage, resources devoted to people with particular diseases, preventive care, the needs of rural areas, patients' voice in deciding health care, etc.

U.S. system of government. __________________________ Some economic, social, or political institutions are inherently resistant to radical change of any kind, because they think that: _________________________________________________________ o Any comprehensive change in the health care system is likely to result in winners and losers. o Even those who are uncertain about how reform will affect them may oppose it because they are risk-averse.

Differences of opinion. ______________________ Any particular reform proposal must overcome resistance from those who favor comprehensive reform, but differ strongly over ways and means by which changes can take place.

2. Factors that are precipitating the needs for a comprehensive reform: _____________________________________________________________ The following forces are flowing together to precipitate a nationwide change. Particularly the seniors are likely to come out as very influencing lobbyist and mobilize policy decision in favor of them when they see that financial crisis with Medicare is precipitating and a shortage of nursing stuff is seriously affecting their health and quality of end-stage-life. Therefore, leadership from the business community, Baby boomers and states might together galvanize comprehensive reform. Theses forces are:

o Wide spread dissatisfaction of: ______________________________________________________ " The business community with employer-based insurance due to rising health care cost and cost shifting by Medicaid providers; " State governments' due to huge fiscal drain of federally mandated, means-tested insurance; and, " Baby boomers,

o Finally, because of continuous campaign of different social and advocacy groups, Americans may realize that the risks of the current system as a whole outweigh the risks of comprehensive reform.

C.4 What kind of comprehensive reform should we choose? ________________________________________________________________ The current care delivery systems cannot solve the problems. Trying harder may not work. Changing systems as a whole - state-of-the-art health care to all Americans with the use of IT to support clinical and administrative processes may prove working in effective manner. The following alternatives could be tested and best alternative be choosen.

C.4.1 "Extending Medicare to the entire American population" (SINGLE PAYER UNIVERSAL COVERAGE) __________________________________________________________________________________

1. Physicians Working Group (PWG) proposed to extend Medicare as 'single payer universal coverage' to cover all age groups including dental services, long term care, prescription drugs and mental health care8. Under this reform: ________________________________________________________________________________________________________________________________________________________________________________________________ o Private health insurance would be sharply restricted or eliminated entirely; o For-profit hospitals and clinics would be phased out over time. o Co-payments and deductibles would be eliminated or held to a minimum; o Hospitals would be funded by an annual budget, fixed in advance; o Physicians would be reimbursed by fee-for-service or salary; o The global budget for the national health insurance program would be set at approximately the same proportion of GDP as in the year preceding its establishment; o Funding could come from income taxes, payroll taxes, or compulsory employer contributions or other progressive taxes.

2. Extending Medicare has following advantages: ________________________________________________________________ o It is the simplest, most straightforward way of achieving universal coverage; o Administrative costs are much lower than they are now, although not always contributing to low overall costs. This may also be attributable to fraudulent practice.; Moreover, extending Medicare reduces wastefulness and inefficiencies in the delivery of health care11; o It reduces uninsured adults with chronic health conditions13; o It increases access regardless of ability to pay, and reduces the severity of epidemics through decreasing the number of disease carriers11; o It aligns incentives for investment in long term health-care productivity, preventive care, and better management of chronic conditions11,14; o A Centralized national database makes diagnosis and treatment easier for doctors11; o Medical professionals can concentrate on treating patients rather than on administrative duties11.

3. But Extending Medicare may have the following disadvantages: __________________________________________________________________ o Negotiated fee schedules have proved to be inadequate in Canada. o Fixed budgets for hospitals with capital outlays controlled by central authorities are unsatisfactory (British NHS). Therefore government may have to free up hospitals to make their own financing decisions. o Unequal access and health disparities still exist in some universal health care systems9, 11. Although this plan is a democratic culture in paper, yet is not in reality. It can not prevent huge socioeconomic differences such as using service of doctors in private practice, use of expensive drugs and technologies (MRI) in a single city; o Individuals may oppose that the health care is not a right and they can not pay taxes for misfortune of others9, 10. In addition, healthy people may not be willing to pay for the burden of those who smoke, or are obese, etc. o Increased waiting times9; and rationing; o Poorer quality of care9,11; o Government agencies may appear less efficient due to bureaucracy and reduce doctor flexibility 9,11.

4. However, Medicare by this time has become popular to many of the consumers particularly among Senior citizens. We may think of extending it, but we must remind ourselves that it has following flaws7 in a nutshell: _____________________________________________ o Medicare is suffering from sky rocketing costs of technologies and FFS to physicians relative to its benefits. Moreover, the spending is difficult to predict or control7. For example, from 2003 to 2004 the bill for physician services jumped 15 percent because of longer and frequent visits, tests and greater use of in-office prescription drugs7. In addition, the Medicare Hospital Insurance Trust Fund is predicted to be depleted by 2019 when baby boomers would become eligible.8 Unless we massively increase taxes or slow the growth of spending, Medicare is headed for financial failure. o Under the new drug plan the legal issue to help seniors enroll quickly, make informed choices and get good coverage at long term settings is becoming intense. Moreover, it is suffering from funding. Part-D plan escalated the yearly spending to 3.3 percent of GDP and that will become 7.5 percent in 2035. o Therefore, to make Medicare succeed, much has to be done with legislative change or reshuffle.

In spite of having different views of opponents, Massachusetts and California are planning to implement single payer universal care from July, 200715, and 16. Although egalitarian view of a single payer universal publicly funded system looks great, however, there is conflict of interests between pressure and interest groups. Ultimately the powerful looser (Insurance companies, single issue groups like healthier people with social value of 'individualism and seniors even) may resist changes. Thus Single payer system may not be able to create a win-win situation.

C.4.2 "Heading toward a "universal Health Care Voucher system" ______________________________________________________________

1. To create win-win situation between possible beneficiaries and loosers should be the aim of a comprehensive reform, because the reforms should come out of pen and paper and has to take effect without resistance. A publicly funded social insurance with elements of choice and competition - a mixed system between single payer universal coverage and individual mandate may achieve the above aim7. This kind of reform was termed as "Universal Health Care Voucher17". The "Universal Health Care Voucher17" may create a win-win situation for the entire stakeholder in following ways: __________________________________________________ o Good news for Baby boomers - It will remove cost concern of Means-testing care: ____________________________________________________________________ Every American would be covered for basic care without means-testing, thus ever growing cost of health care would not be a concern;

o Good news for single issue groups: __________________________________________ The financial burden would be distributed fairly according to a person's consumption, because the voucher plan would be funded by an earmarked value-added tax (VAT) not by payroll and income tax. Moreover, for the public as a whole, there would be a direct connection between the level of benefits and the level of taxes.

o Good news for Private sector business firms and tight labor market: ____________________________________________________________ Labor markets would work more efficiently because neither workers nor firms would take job seeking / hiring decisions on superfluous health insurance considerations. Thus, a major source of management-labor friction would be eliminated.

o Good news for State governments: _____________________________________________ State governments would be relieved of the large financial and administrative burdens associated with the means-tested programs.

o It is more congruent with fundamental American individual value: ________________________________________________________ The proposed voucher system may provide basic care for all with freedom to choose among competing plans and purchase more than the basic care. Thus it is more congruent with 'Right to freedom' than single-payer proposals that emphasizes equality or HSAs. Conversely, elements of secured basic care would ensure "freedom of rights".

2. However, The Voucher system may have to answer the following question before it gets success: __________________________________________________________________________ o Most of the 1,000 health insurance companies would disappear. Therefore, state government has to sustain their pressure and resistance; o Risk-adjusted capitation will require changes in organization and delivery. o Moreover, the following questions have are answered: _______________________________________________ " How would very few health plans qualify to participate particularly in rural area and small towns where population density is dispersed? " What kind of reimbursement system would reward efficient and cost-effective care without creating incentives for stinting and adverse selection? " How would the transition from the existing system be handled? " What would be the demarcation line between universal benefit and that beyond universal benefit? " How would disputes about coverage and malpractice be handled? " How would funding for research and education be provided?

4. The bottom line: _____________________________________________

Universal basic care should ensure quality care. There are roles and responsibilities of all the stakeholders to make universal system work. Whatever the kind of reform may be, without transforming health care delivery system, the quality can't be achieved and reform benefits can't be sustained. For this we may take some steps designed by Committee on the Quality of Health Care in America. These are:

1. Role of all stakeholders-Commitment: __________________________________________________ To ensure UHV, all stakeholders commit to meeting "safe, patient centered, timely, efficient and effective care". Focusing on these aims would enable health care system to meet patients' needs including full array of preventive, acute, and chronic services that is safer, more reliable, responsive, integrated, and available. Moreover, this will continually reduce the burden of illness, injury, disability and improve the health and quality of life.

2. Role of Government and employers: ______________________________________________________ o Funding and monitoring improvement in thrust sectors: __________________________________________________ " 15-25 priority chronic conditions like cancer, diabetes ischemic heart disease; stroke, etc. should be identified to start with meeting the above mentioned aims; " Strategies, goals, and action plans including prevention plans to remove the perils of these chronic conditions for achieving substantial improvements in quality in specified time should be developed; " Adequate resources should be deployed to stimulate following change process as follows;

o Changing environment: ___________________________________ Environmental changes need to occur in four major areas: _____________________________________________________ I. Building national IT backbone: ___________________________________________ The automation of clinical, financial, and administrative information and the electronic sharing of such information among clinicians, patients, and others within a secure environment are critical for quickly improving quality health care. New IT backbone should support: ________________________________________ " Health care delivery, " Consumer health, " Quality measurement and improvement, " Public accountability, " Clinical and health services research, and " Clinical education.

II. Research and realign current payment methods and policies: ____________________________________________________ Employers and CMS may examine current payment methods to remove barriers and add incentives for quality improvement. Possible means include3: ______________________________________________________________ " Blended methods of payment for providers and bundle payments for priority conditions; " Multiyear contracts, " Realign incentives: ___________________________ o to use of EDI among clinicians and between clinicians and patients, o to concentrate on designing process based best practices that achieve better patient outcomes; o to improve performance, outcome and quality

" Risk adjustment for all stakeholders, " Alternative approaches for addressing the capital investments needed to improve quality. " Ensure an environment, through use of IT so that consumers and purchasers understand the quality differences at different cost and direct their decisions accordingly; " Reduce fragmentation of care. Payment methods should not pose a barrier to providers' ability to coordinate and integrate care for patients across settings and over time.

III. Preparing the workforce to better serve patients in a world of expanding knowledge and adopt accelerating changes. ___________________________________________________________ Ensure multidisciplinary efforts of leaders within the health professions to discuss and develop strategies for: __________________________________________________________ " Restructuring undergraduate, graduate clinical education for medical, nursing, and other professionals. Ongoing training programs to be consistent with the principles of this new health system; ." Ensuring ongoing licensure and certification that reflect the need for lifelong learning and evaluation of competencies for health professionals; " Incorporating of performance and outcome measurements for improvement and accountability.

IV. Reforming the current regulatory and legal systems for transitions: ________________________________________________________ Funding research to evaluate how the current regulatory and legal systems: _____________________________________________________________ " Facilitate or inhibit the changes needed for proposed health care delivery system; and " Can be modified to support health care professionals and organizations to accomplish the six aims set forth in.

3. Role of Health Care organization: ________________________________________________________ Design and implement more effective organizational support processes to make change sustainable. The future health care delivery should focus on following 10 innovative rules: ________________________________________________________________ I. Care based on continuous healing relationships. _________________________________________________________ Care providers should focus on 'when and where' the consumers need the service. Health care should be available round the clock basis and over the Internet, by telephone, and by other means in addition to face-to-face visits. II. Customized health care: _____________________________________________ Health care should be responsive to 'customers' voice - needs and preferences. III. The patient as the source of control. ________________________________________________ Health care should be designed on patients' informed choice and encourage shared decision making. IV. Shared knowledge and the free flow of information - Knowledge management: ____________________________________________________________________ " Automate clinical information; develop an IT infrastructure needed to support the provision of care, the ongoing measurement of care processes and patient outcomes. " Patients should have free access to Personal health information and to clinical knowledge. The information must accompany patients as they transit from home to clinical office setting to hospital to nursing home and fall back. " Case and care management: Multidisciplinary coordination of care across chronically ill patient conditions, services, and settings - among caregivers and between caregivers and patients. This over time can reduce the need to craft laborious, case-by-case strategies for coordinating patient care. V. Evidence-based decision making. ___________________________________________ " Organize evidence-based collaborative care processes consistent with best available scientific knowledge and practices to serve more effectively the needs of the chronically ill; " Common clinical guidelines / routines that may ensure coordinated, flawless care across settings and clinicians and over time. Moreover, care will not vary illogically from clinician to clinician or from place to place; " Widespread application of common practice will require commitment. Evidence-based care should be supported by automated clinical information and decision support systems that is responsive to individual patients' needs and preferences. VI. Safety as a system property. _________________________________________ The system should reducing risk of injury and ensure safety. Greater attentions should be given to system that prevents and mitigates medication errors. VII. The need for transparency to facilitate informed decision of patients. ____________________________________________________________ The care should allow consumers to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. Marketing care should focus on free and flawless information describing the system's performance on safety, evidence-based practice, and patient satisfaction; VIII. Anticipation of needs. _______________________________ The care should focus on patients' wants and needs -the 'means-end chain', rather than simply reacting to events. IX. Continuous decrease in waste. ___________________________________________ The health system should not waste resources or patient time. X. Cooperation among clinicians. __________________________________________ Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information.

"All care provider must realize that Evidence-based, patient-centered and systems-oriented care is the present wants and needs of consumers. Taking advantage of IT will be an important catalyst to moving to this end."

4. The role of Purchasers, regulators and professionals-Creating supportive environment by realigning payment incentives: ________________________________________________________________

These roles would empower patients to make informed choice and would direct health care dollars more to patients rather than to administrative costs.

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