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In 2008 Medicare stopped reimbursing hospitals for treating eight avoidable hospital-acquired conditions. Using 2006 California data, we modeled the financial impact of this policy on six such conditions. Hospital-acquired conditions were present in 0.11 percent of acute inpatient Medicare discharges; only 3 percent of these were affected by the policy. Payment reductions were negligible (0.001 percent, or $0.1 million—equivalent to $1.1 million nationwide) and are unlikely to encourage providers to improve quality. Options to strengthen the incentives include further payment modifications for hospital-acquired conditions or expanding the hospital-acquired condition policy to exclude payment for consequences, additional procedures, and readmissions. [ABSTRACT FROM AUTHOR]

In this article, the author expresses his views on the implications of the health care reform in the U.S. in 2009 for physicians. The aim of the health care reform under the administration of U.S. President Barack Obama is to augment the number of Americans who have health insurance coverage. The author also identifies the two tools that health plans may use to control cost including fee reductions for providers and financial disincentives for patients.

The article presents an editorial that discusses a potential U.S. health care reform system that features elements of universal health care coverage plans. The proposed plan would combine universal risk pools, mandated health care coverage with income-based subsidies, and a restructured payment mechanism. Medicare is discussed and is described as the prototypical single-payer model of health care coverage. Employer-supplied health insurance is also discussed. The article also discusses care delivery teams.

An important aspect of the mandate assessments requested by the California legislature is a review of the scientific and medical literature on the medical effectiveness of the proposed health insurance benefit mandate. Although such a review bears many similarities to effectiveness reviews that might be undertaken for publication as research studies, several important differences arise from the requirements of the California legislation. Our reviews are intended to assist the legislators in deciding whether to support a specific mandate to modify health insurance benefits in a particular way. Thus, our assessments focus on how the scientific literature bears on the proposed mandate, which may involve a complicated chain of potential effects leading from altered coverage to ultimate impact on health. Evidence may be available for only some of the links in the chain. Furthermore, not all the evidence may be directly applicable to the diverse population of California or the subpopulation affected by the mandate. The mandate reviews, including the medical effectiveness analyses, may be used in a potentially contentious decision making setting. The legislative calendar requires that they need to be timely, yet they must be as valid, credible, and based on the best information available as possible. The focus on applicability also implies the need for informed, technical decisions concerning the relevance of the articles for the report, and these decisions need to be made as transparent as possible. These goals and constraints yield an approach that differs somewhat from an investigator-initiated review of the literature. [ABSTRACT FROM AUTHOR]

Most observers agree that the US healthcare system is expensive, provides variable quality and leaves many without coverage. The policy challenge is that there is little consensus on how to approach reform. Many proposals assume that systems appearing to work in one nation can be transferred in toto to another or, alternatively, that only minor tweaking of an existing system is possible. The former approach ignores fundamental social, political and legal realities, and the latter ignores the potential for increased benefits. Additionally, many proposals are ideologically driven, focusing on how to finance expanded coverage. Broadening the discussion to examine other components of the system that do not work well may identify sufficient benefits for various stakeholders to engage them in finding more comprehensive solutions that address a range of problems. This paper examines areas in which the US healthcare system performs worse than one would like and areas in which it appears to work well. In the first category is the high proportion of people without coverage, the inefficient and inequitable incentives for the purchase and provision of insurance, the problems in deciding what should be covered, the ineffective payment incentives, administrative costs and complexities, the variable quality and lack of responsiveness to patient preferences, the less than optimal safety, under-valued primary care, provider de-professionalisation, and the costs that appear to be on auto-pilot. In the second category is the rapid and wide-reaching technological innovation, the ready access to care for the insured, and clinical and patient autonomy. Among the things taken as given is our constitutional (rather than parliamentary) political system and underlying public values about the roles of individuals and government. Current players will be active in any debate about reform, so their interests must be addressed. Likewise, certain underlying economic and social drivers of behaviour will continue and should be considered in any reform proposal. Potentially changeable, however, are the roles and functions that the current players may take on in a new system. Likewise, health system-specific legislation should be as malleable as are financing approaches. A more expansive view of the health system's problems makes potential solutions more complex. By addressing problems faced by people currently with coverage and by providers and other stakeholders within the system, however, the benefits may be sufficiently widespread to create the political consensus that has so far eluded reformers in the US. [ABSTRACT FROM AUTHOR]

When paid a fixed amount per capita, even if adjusted by demographic risk factors, health plans have financial incentives to avoid providing expensive services, especially those needed on a chronic basis. Since routine measurement of quality of care is limited primarily to preventive service utilization, the potential for patients with serious chronic disease to receive poor quality care is significant. We argue that both adjustment of payments to health plans based on the illness burden among their enrollees and measurement of quality of care will be necessary to ensure health plans provide high quality care. For some costly chronic diseases, condition-specific risk adjustment and quality measurement using data already collected for clinical management purposes may be necessary. We provide two examples (HIV and CF) and discuss the implications for information systems. [ABSTRACT FROM AUTHOR]

The paper in this issue of the "Journal of Health Economics" entitled "The effect of market structure on HMO premiums" comes at a crucial time in the health reform debate. While much of the discussion in the press has focused on the role of mandates and other devices to assure universal coverage, or at least universal access to coverage, the details of how the health care system should be structured help determine, both directly and indirectly, the choices among various proposals. At one extreme are the proposals for a single payer system and an extension of the Medicare program to cover the non-elderly without private insurance. At the other extreme are proposals ranging from minimal interventions to just let the market work, to the proposal which focuses on managed competition among HMO and similar organizations to keep costs under control. There is a fairly large and continuously growing literature on HMO performance, including utilization of various types of services, estimated costs of these services, quality, and patient assessments.

This article comments on the reanalysis made by dean Kip Sullivan on managed care plan performance in the U.S. Sullivan argues that one should base evaluations of quality in managed care plans only on research in which coverage and benefits in various settings are comparable. He states that the impact of differential financial barriers on care-seeking behavior should be excluded from such assessments. Applying this insurance criterion decrease substantially the number of reanalysis research with outcomes favorable to health maintenance organizations. Health plan choices are made among various options, sometimes by employers or policymakers, sometimes by patients. As a whole, choices are made among plans that have various principal mechanisms for cost containments.

Billing and insurance-related functions have been reported to consume 14 percent of medical group revenue, but little is known about the costs associated with performing specific activities. We conducted semistructured interviews, observed work flows, analyzed department budgets, and surveyed clinicians to evaluate these activities at a large multispecialty medical group. We identified 0.67 nonclinical full-time-equivalent (FTE) staff working on billing and insurance functions per FTE physician. In addition, clinicians spent more than thirty-five minutes per day performing these tasks. The cost to medical groups, including clinicians' time, was at least $85,276 per FTE physician (10 percent of revenue). [ABSTRACT FROM AUTHOR]