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In 2016, in anticipation of the US presidential election and forthcoming new administration, the National Academy of Medicine launched a strategic initiative to marshal expert guidance on pressing health and health care priorities. Published as Vital Directions for Health and Health Care, the products of the initiative provide trusted, nonpartisan, evidence-based analysis of critical issues in health, health care, and biomedical science. The current collection of articles published in Health Affairs builds on the initial Vital Directions series by addressing a set of issues that have a particularly compelling need for attention from the next administration: health costs and financing, early childhood and maternal health, mental health and addiction, better health and health care for older adults, and infectious disease threats. The articles also reflect the current experience with both the coronavirus disease 2019 (COVID-19) pandemic and the health inequities that have been drawn out sharply by COVID-19, as well as the implications going forward for action. [ABSTRACT FROM AUTHOR]

The authors comment on a study by W. H. Shrank and colleagues, published within the issue on the estimates on the proportion of U.S. health care spending that is wasteful. Topics discussed include categories of wasteful health care spending, reasons that major policy initiatives led to limited financial savings, and factor that may help clinicians and patients make better decisions.

Importance: Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost.Objectives: To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity.Evidence Review: Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings.Findings: The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress.Conclusions and Relevance: The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress. [ABSTRACT FROM AUTHOR]

To succeed, health care reform must slow spending growth while improving quality. We propose a new approach to help achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and "shared savings" payment reform. The approach is practical and feasible: it is voluntary for providers, builds on current referral patterns, requires no change in benefits or lock-in for beneficiaries, and offers the possibility of sustained provider incomes even as total costs are constrained. We simulate the potential expenditure impact and show that significant Medicare savings are possible. [ABSTRACT FROM AUTHOR]

Presents a speech by U.S. Food and Drug Administration commissioner Mark B. McClellan, delivered at the Case Western Reserve University's Schroeder Lecture, October 7, 2003. Concern over the increasing medical spending and access to quality care; Factors responsible for the high prices of medicines in the U.S. compared to other countries; Adverse effects of the liability system on medical care.

To assess the consequences of advance medical directives—which explicitly specify a patient’s preferences for one or more specific types of medical treatment in the event of a loss of competence—we analyze the medical care of elderly Medicare beneficiaries who died between 1985 and 1995. We compare the care of patients from states that adopted laws enhancing incentives for compliance with advance directives and laws requiring the appointment of a health care surrogate in the absence of an advance directive to the care of patients from states that did not. We report three key findings. First, laws enhancing incentives for compliance significantly reduce the probability of dying in an acute care hospital. Second, laws requiring the appointment of a surrogate significantly increase the probability of receiving acute care in the last month of life, but decrease the probability of receiving nonacute care. Third, neither type of law leads to any savings in medical expenditures. [Copyright &y& Elsevier]

Previous research suggests that “direct” reforms to the liability system—reforms designed to reduce the level of compensation to potential claimants—reduce medical expenditures without important consequences for patient health outcomes. We extend this research by identifying the mechanisms through which reforms affect the behavior of health care providers. Although we find that direct reforms improve medical productivity primarily by reducing malpractice claims rates and compensation conditional on a claim, our results suggest that other policies that reduce the time spent and the amount of conflict involved in defending against a claim can also reduce defensive practices substantially. In addition, we find that “malpractice pressure” has a more significant impact on diagnostic rather than therapeutic treatment decisions. Our results provide an empirical foundation for simulating the effects of untried malpractice reforms on health care expenditures and outcomes, based on their predicted effects on the malpractice pressure facing medical providers. [Copyright &y& Elsevier]

Focuses on a study which examines the relationship between liability reforms, malpractice pressure, and physician perceptions of medical care, and estimates the impact of reforms on trends over time both in measures of malpractice insurance pressure and in physician perceptions of the importance of malpractice-pressure-induced changes in practice patterns. Details on the study; Results of study; Conclusion of study.

Cancer care suffers from many of the well-known flaws in the American health care delivery system. Most of the care delivery shortfalls and inefficiencies can be tied, in part, back to payment systems that support high-cost procedures rather than focusing on assisting providers in improving the outcomes of individual patients and the value of care being delivered. We describe various new models of physician payment that can serve as a foundation for a shift away from the current reimbursement system for cancer care to support better outcomes and avoid preventable costs. These recent payment reforms include the implementation of clinical pathways, bundled or episodic payments, payments tied to quality improvements, and the patient-centered oncology medical home. We then describe how these reforms can be supported in a blended payment model that transitions away from, but still contains elements of, fee-for-service payments. [ABSTRACT FROM AUTHOR]