Health care reform

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Health care reform is "innovation and improvement of the health care system by reappraisal, amendment of services, and removal of faults and abuses in providing and distributing health services to patients. It includes a re-alignment of health services and health insurance to maximum demographic elements (the unemployed, indigent, uninsured, elderly, inner cities, rural areas) with reference to coverage, hospitalization, pricing and cost containment, insurers' and employers' costs, pre-existing medical conditions, prescribed drugs, equipment, and services."^[1]

Individual states have not been able to reform health care.^[2] Many proposals have been made in the United States of America at the national level for reform,^[3] and the Patient Protection and Affordable Care Act, a major reform package, became law in March 2010 after a major political fight.

Health care cost[edit]

Health care costs are "the actual costs of providing services related to the delivery of health care, including the costs of procedures, therapies, and medications. It is differentiated from health expenditures, which refers to the amount of money paid for the services, and from fees, which refers to the amount charged, regardless of cost."^[4]

Regarding the increases in cost of the health care sector in the United States of America, one cost-benefit analysis concluded, "on average, the increases in medical spending since 1960 have provided reasonable value."^[5]

Sources of unnecessary costs[edit]

Administrative costs[edit]

The costs of administration of health care in the United States of America in higher than the costs in Canada.^[6]

Conflict of interest[edit]

Doctors who receive income from referring patients for medical tests have been shown to refer more patients for medical tests presumably due to conflict of interest.^[7]

Insufficient access to prior medical records[edit]

Sometimes diagnostic testing is redundant because of inadequate access to prior medical records.^[8]

Unnecessary care[edit]

Unnecessary is common^[9][10] and may be motivated by financial conflict of interest^[7].

Problems in resource and cost allocation[edit]

Market forces[edit]

Large payers often negotiate significant discounts with providers. The discounted prices may not cover the cost of some services, but the payer sees an overall advantage from volume in the payer network.

Unfunded mandates[edit]

EMTALA requires U.S. emergency facilities to examine and stabilize patients, without checking ability to pay. This can be lifesaving, but, even in true emergencies, a hospital can easily accumulate hundreds of thousands of dollars in costs for stabilizing a gunshot wound victim. If that victim is uninsured, EMTALA provides no means of reimbursement.

Cost shifting[edit]

To cover actual costs, providers may increase their prices to providers with less market leverage, and charge the highest "list" prices to uninsured people who are "self-pay".

Proposed interventions[edit]

Increased preventive health care[edit]

Regarding the opportunity cost of primary prevention of diseases, one analysis concluded, "opportunities for efficient investment in health care programs are roughly equal for prevention and treatment."^[11]

Patient-centered medical home[edit]

The patient-centered medical home as been described^[12] and promoted by various organizations^[13]

Improved availability of prior medical records[edit]

Having the results of prior tests available may reduce the need for repeating tests.^[14] A randomized controlled trial has shown reduction in ordering of redundant tests.^[15]

Public reporting of outcomes[edit]

See also: Health care quality assurance

Reimbursement changes[edit]

Financial risk sharing[edit]

Financial risk sharing may be implemented through accountable care organizations^[16], global payments^[17], capitation fees, or prospective payment systems.

Pay for performance[edit]

For more information, see: Pay for performance.

In one study, pay for performance did not improve the care of hypertension.^[18] However, a systematic review of older studies suggested possible benefit.^[19]

Place doctors on salary[edit]

Placing doctors on salary has been proposed to avoid the conflict of interest in the fee-for-service plans.^[20][21][22] Similarly, abandonment of fee for service has been advocated.^[23] Salaried physicians may be more receptive to clinical practice guidelines.^[24]

Whether placing doctors on salary has only been studied in primary care.^[19]

Health services accessibility[edit]

Health services accessibility is "the degree to which individuals are inhibited or facilitated in their ability to gain entry to and to receive care and services from the health care system. Factors influencing this ability include geographic, architectural, transportational, and financial considerations, among others."^[25]

Proposed interventions[edit]

The 1993 Clinton health care plan proposed a mandate that employers pay 80 percent of the average premium of health care plans for their employees.^[26]

In 1976, President Carter proposed comprehensive national health insurance system with universal and mandatory coverage.^[27]

In 1965,President Johnson proposed and implemented Medicare and Medicaid.^[28]

In 1949, President Truman proposed national health insurance.^[29]

Malpractice reform[edit]

Reform of medical malpractice is sometimes included as a component of health care reform.^{[30][31][32][33][26][34]}

Enterprise liability[edit]

The American College of Physicians has suggested demonstration projects test the feasibility of enterprise liability.^[35][36]

Comprehensive proposals[edit]

Several alternatives are in the U.S. Congress, such as the Baucus bill introduced by the Gang of Six.

President Obama[edit]

President Obama summarized his plan.^{[37][30][32][38]}

His House Bill is H.R. 3200 and includes an expansion of Medicaid.^[39] The Congressional Budget Office has published their budgetary projections which states, "enacting H.R. 3200 would result in a net increase in the federal budget deficit of $239 billion over the 2010-2019 period."^[40]

President Clinton[edit]

President Clinton summarized his plan.^[26] The Clinton plan included mandatory:^[41][42]

• states creating not-for-profit health care cooperatives or alliances. The alliances would approve health care plans that offer care paid by salary, capitation fee, or fee-for-service plans.
• employers paying 80 percent of the average premium of health care plans.

The Clinton plan was defeated, "the Senate Finance Committee did approve a bill in July 1994 that would have extended health insurance to 95 percent of the population by 2002, but the bill stalled in debate on the Senate floor and never came to a vote."^[43] The defeat was interpreted as being "rejected by a public that came to see it as a bid to replace their family doctor with the Bureau of Motor Vehicles writ large."^[43]

References[edit]