Advocates for Evidence-Based Health Policy Speakers
2010 Year in Review
The past year has been more monumental for health policy unlike any other time since the enactment of Medicare. Yet, the Patient Protection and Affordable Care Act, delivered by Congressional Democrats and President Obama, will be viciously challenged by Republicans in the new year.
1. Health system reforms from around the world illustrate the search for universal coverage.
While the details of such plans are as diverse as the populations they serve, healthcare reforms implemented in , the , , , , and share the drive to provide basic insurance coverage for all citizens. The common thread in the majority of these efforts is mandated insurance obligating citizens to enroll in a basic level of government defined health coverage. These basic plans are often offered on a not-for-profit basis with for-profit supplemental products offered in lieu of, or in addition to base plans. Some systems foster a market of managed competition where guaranteed issue prevents denial of coverage based on pre-existing health conditions. Each of these reforms typically has a tax based financing plan whether the government pays upfront, or provides subsidies in the form of credits, deductions, or rebates.
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2. The Patient Protection and Affordable Care Act takes its cues from foreign health reforms on the road to universal coverage but challenges remain.
The United States has followed suit with the reforms of other countries by incorporating community rating, guaranteed issue, individual mandate, and a into the federal healthcare reform law. Issues the U.S. health reform still faces involve the implementation of health IT and electronic health records to meet the standards of meaningful use requirements, network overlap, issues of malpractice reform, and decisions between uninsured and over-insured while increasing the number of covered individuals.
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3. Tort reform is a means to curb the rising costs of medical malpractice premiums.
estimates break down into indemnity payments (payouts to defendants), administrative expenses (plaintiff’s and defense attorney fees, the overhead costs of insurers, and of risk management programs), and defensive medicine (performing tests or therapies that provide little or no value to the patient in order to prevent threat of lawsuit.) To date, tort reform as a significant means of decreasing medical costs to Americans is based on little evidence. Published studies raise questions concerning the significance of direct (caps on damages) or indirect (liability reform and limits on plaintiff attorney contingency fees) tort reform effects on physician practices, the true costs of , and the estimated impact malpractice premiums have on the cost of health care. Research demonstrates that capping malpractice insurance premiums shows no downstream savings for health care consumers. Even if malpractice premiums were reduced significantly, it would only reduce total health care costs by less than 1 percent. Total medical liability costs, including estimates of defensive medicine, are estimated to account for only 2.4 percent of overall health care costs.
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4. Tying financial costs and benefits to providers may improve healthcare quality.
New payment models are being tested that attempt to align provider incentives with improved efficiency and quality of care. The underlying strategy of these models is to shift provider behaviors from treating acute episodes to managing patients across a continuum of care. To achieve this goal, public and private insurers intend to from payer to provider. Implementation of these methods may manifest as reserving a portion of reimbursement for activities known to improve quality as in (P4P), or by making providers responsible for the(Post Acute Management), hospital based procedures (Acute Care Model), and care coordination (Chronic Care Model or Community Wide Cost Management).
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5. The U.S prepares for the era of electronic health records (EHRs)
Between 2008-2009 research shows an increase in the in the United States from 7.2 percent to 9.2 percent of providers. By 2010, 11.9 percent of hospitals surveyed had some form of EHR. Smaller and medium size hospitals and critical care facilities were significantly less likely to have EHRs. The same study speculated that very low numbers of those facilities, who already have EHRs, will meet. Meaningful use requires EHRs to meet 15 core objectives, and to select 5 additional criteria from a list of optional choices. The American Recovery and Reinvestment Act currently offers financial incentives for ERH implementation, but in 2015, those incentives will turn to penalties.
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6. Evidence Based Health Policy: The role of evidence in developing health policy.
seeks to inform policy makers by demonstrating a burden exists, clearly showing a benefit or harm, prioritizing one issue over another, explaining relevance to local populations, and outlining costs. Quality of evidence must be considered before policy makers decide to act. grades its recommendations based on the quality of the evidence. Strong policy is transparent, and the underlying evidence is easy for stakeholders to understand. Finally, once a policy is implemented, it is critical to monitor and evaluate it’s outcomes for intended and unintended effects.
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7. The United States Preventive Service Task Force must avoid the politics of policy.
The USPSTF is a sixteen member panel of independent medical experts charged with making recommendations concerning clinical preventive screening, medication, and counseling based on scientific evidence. The panel’s recommendations are give specific grades based on strength of evidence. The Patient Protection and Affordable Care Act requires health insurers to cover preventive services with a. The task force has come under fire recently with its recommendation against for women under age 50 and again for postponing a vote on the . These decisions, along with their new found influence under federal health care reform, will undoubtedly bring about intense scrutiny of future recommendations.
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8. Delivering healthcare quality requires a multifaceted approach.
Healthcare quality improvement requires changes at every level of the healthcare system. Health IT, payments system reforms, and improved access to care are all key elements of delivering improved care. Health IT and electronic health records seek to improve patient care coordination, reduce mistakes, and track patient outcomes. New payment systems that align financial incentives with measures of quality and care coordination including Pay for Performance, Post Acute Management, Acute Episode Bundling, Chronic Care Models, and Community Wide Cost Management seek to decrease unnecessary and repetitive treatment by shifting financial responsibility for these procedures to the providers. Finally, alternative approaches to improving access to care including and demonstrate improved outcomes in the populations they serve.
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9. Access to care means moving beyond private physician offices and Emergency Rooms to retail clinics and classrooms.
Emergency Departments (EDs) continue to be ready source of care for millions of Americans due to their , the requirement that they treat all patients regardless of insurance type, and the ability to provide treatment for conditions urgent care centers and retail clinics are ill equipped to handle. However it is estimated that 13.4 and 13.7 percent of ED visits could safely, and more cost effectively, be diverted to retail clinics and urgent care centers, respectively. Instead of looking to retail clinics and urgent care centers as a cheaper mode of acute care, policy makers must look at how to best and promote the continuity of care with
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10. Uninsured individuals put themselves at higher risk for significant loss of assets.
It is estimated that anywhere from between 50-62 percent of are the result of medical illness. Research demonstrates uninsured individuals who encounter new illness lose one quarter to one third more assets when compared to those who are uninsured and healthy or insured and encounter new illness. provides a unique opportunity to compare 30,000 new Medicaid enrollees to an uncovered population to examine the impact of having no health insurance. The data collection concludes at the end of 2010. The Oregon Health Study promises a fascinating comparison of an uninsured versus a newly insured population once its data has been analyzed and published.
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by
Patrick Fitzgerald, MPH