Improving Value in Healthcare

Improving the Quality and Lowering the Cost of Health Care: Medicare Reforms from the National Commission on Physician Payment Reform

Is it worth the effort to create a learning healthcare delivery system?

The Patient Protection and Affordable Care Act (PPACA) created dramatic changes in the healthcare payment and delivery systems in the United States. Widely hailed as the largest restructuring of healthcare delivery since the Johnson administration, the PPACA has been reshaping the American healthcare landscape since 2010. While much of the discussion surrounds the original contents of the bill, it is important to consider the changes in the legislation since its enactment 3 years ago. Although these changes can easily be interpreted through a partisan lens, it is critical to consider the evolution of the PPACA as objectively as possible, in order to better understand the potential impact of shifts in policy. The following discussion will attempt to (1) describe the three major changes in the PPACA since its passage in 2010; and (2) reflect on the implications for the overall American healthcare system and orthopaedic surgeons.

APhA advances provider status initiative

The 2011 ESRD Prospective Payment System: Perspectives From Fresenius Medical Care, a Large Dialysis Organization

With the passage of the Affordable Care Act (ACA) in 2010, broad agreement has been reached on the need for fundamental reform of healthcare delivery and payment systems. Accountable care organizations (ACOs) have become one of the most discussed provisions of the ACA, and Medicare's Shared Savings Program (SSP), the incentive program tied to ACOs, has the potential to change the delivery of healthcare. The SSP will attempt to improve the quality of care while reducing the growth in expenditures by encouraging the formation of ACOs. The SSP is voluntary, and organizations that wish to participate will encounter advantages and disadvantages in its adoption. This article provides hospital administrators with basic information about the ACO requirements set forth by the Centers for Medicare & Medicaid Services and helps frame decision making about hospital participation in ACOs.

ACO payment models and the path to accountability.

Although the American health care system is the most expensive in the world, it delivers inconsistent (and sometimes poor) quality of care. Recent health care legislation contains several delivery system reforms that will attempt to address these issues. We review these programs and discuss the implications for practicing urologists. We evaluated the medical, legal, and public policy literature (both print and electronic) related to contemporary health care reform efforts. We summarized the Patient Protection and Affordable Care Act of 2010 (PPACA) and examined four cost-containment and/or quality-improvement mechanisms related to Medicare payment policy that will be implemented by this recently passed law. The PPACA will expand health care coverage and promote bundled payment systems, accountable care organizations, and the patient-centered medical home as the vehicles for containing cost and improving health care quality. The legislation will also establish an independent commission to enact cost-containment policy, which may have significant implications in terms of physician reimbursement. Although the recent health care legislation broadens coverage for millions of Americans, there are limited data demonstrating the effectiveness of the cost-containment and quality-improvement mechanisms established by this law. Results from recently initiated pilot programs will emerge over the coming years, and it remains to be seen how health care costs and quality will be affected.

The current US health care system is expensive,1 provides an uneven quality of care,2 and leaves about 40% of US adults uninsured or underinsured.3 The medical education system in the United States may contribute to these problems through its emphasis on the treatment of disease rather than addressing patient safety, cost-effective health care delivery, and population health. Graduate medical education (GME) occurs at the fulcrum of clinical care delivery and medical school, and could play an important role in altering medical education to better address features of clinical quality, health care costs, and access to health services. In the process, GME could bring about needed improvements in the delivery of health care services and prevention of disease and injury. To accomplish these goals, GME will have to build bridges between the clinical and educational enterprises. GME could begin a radical reconceptualization of the medical education continuum through the blending of health services concepts and competencies with traditional biomedical, bioscience models. In doing so, the prioritization of time and effort for residents and faculty would have to change to allow excellence in clinical quality to become the driving force for GME, and ultimately for the continuum of medical education.

The Road Ahead

Report of the AACP Task Force on Patient-Centered Medical Homes and Accountable Care Organizations

This paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influen...

Millions of dollars are being spent on the quest for the best means to assess, monitor, and the quality of health care in the United States and on making physicians, health plans, and hospitals accountable. Toward this end, participants in this ever-expanding arena are earnestly trying to develop universal quality standards and regulatory mechanisms. Hospital personnel are desperately trying to adapt to this imperative under two significant conditions that are prompted by the drive to stem costs : (1) the redesign of hospitals, resulting in extensive changes in work roles and the division of labor; and (2) the provision of clinical procedures on an outpatient basis to reduce the length of hospital stay. Consequently, patients who are hospitalized are much sicker than they used to be, while nursing and support staff have been reduced to save money. Meanwhile, a disjunction exists between the nature of quality being measured and the meaning people place on their experiences with health care delivery. Based on five years of research that focused on the evolution of the enterprise, this article demonstrates the usefulness of the framework that was central to the work of Anselm Strauss action, negotiation, and social arenasfor analyzing this complex endeavor. The fit of business techniques and methods currently being used to advance hospital is viewed in relation to the complexity of medical work and the fast pace of change in biotechnology. Amid the pressure to curtail health care spending, an elaborate enterprise costing millions of dollars has been constructed for the purpose of assessing and monitoring the quality of health care in the United States in an effort to improve performance/' in the current language, and to make physicians, health plans, and hospitals more accountable. A growing cadre of people computer specialists, researchers, health care economists, health policy experts are earnestly seeking the means to measure the outcomes of hospital care. This accountability endeavor is occurring under two significant conditions that are prompted by the drive to stem * Direct all correspondence to: Carolyn L. Wiener, Box 0610, Department of Physiological Nursing, University of California at San Francisco, San Francisco, CA 94143; e-mail : carolyn.wiener@nursing.ucsf.edu. Sociological Perspectives, Volume 43, Number 4, pages S59-S71. Copyright © 2000 by Pacific Sociological Association. All rights reserved. Send requests for permission to reprint to: Rights and Permissions, University of California Press, Journals Division, 2000 Center St., Ste. 303, Berkeley, CA 94704-1223.

Some aspects of health care in the United States would be beneficial to Australia and New Zealand, but others should be avoided. Positive aspects, which should be emulated, include: •health care reform that is focused on the continuum of care and patient-centred care •trials of new models to organise, deliver and pay for health care services, where quality of care is rewarded over quantity of services •an integral view of, and strong support for, health services research as a means of evaluating reforms aimed at improving patient outcomes and systems-level efficiencies •physician engagement in reforms--for example, participating in the Choosing Wisely initiative, and trialling and implementing new payment models that are not fee-for-service. Negative aspects, which should be avoided, include: •increasingly fragmented provider and financing structures (funding provided by state and federal governments, private insurance and out-of-pocket costs) that cause frustration in terms of access and care coordination and increase administrative waste •an overemphasis on technological solutions, with insufficient acknowledgment of the importance of addressing value in health care •a focus on hospital and doctor-based health care rather than environmental and social inputs into health.

Fact: As a nation, medical care expenditures represent 10.6% of the gross national product. The portion of the nation's medical care dollar coming from federal sources declined slightly (42.6% to 41.4%) between 1981 and 1984, but this share is more than 15 percentage points above the comparable figure from the years prior to 1965 (Anderson, 1985).As these numbers illustrate, paying for health care is a very expensive proposition in the United States, consuming a higher proportion of our nation's resources than is true for most developed nations. While we have strongly resisted any move to a government-run system of health care delivery, the above numbers also show clearly that the federal government pays for a substantial share of all health care in this country.Three major themes have dominated the health policy agenda during recent years: access to health care, cost containment, and quality of care. The fates of these issues have waxed and waned over the years as changes in health care delivery, federal budgetary politics, and shifting public opinion have altered the environment over time. In the 1960s, access was the key issue, as Democratic administrations used government programs to make health care more readily available to all Americans. As inflation levels soared in the 1970s, cost containment was forced onto the agenda, resulting in a series of attempts to reduce federal expenditures on hospital care. Finally, by the mid-1980s, cost containment pressures were modifying slightly; we have recently witnessed a return to access issues and the emergence of quality as a new political issue.