Practices receive payments that appropriately recognize the added value provided to patients Change payment policies to provide physician case management fees for care coordination services Encourage the use of EMRs Encourage the use of and exchange of electronic health care information Provide incentives for coordinated, patient-centered care advanced medical home Use evidence-based performance measures to improve the quality of care and providing incentives, including financial incentives, to reward physicians who meet or exceed standards Pay physicians for computer-based consultations Pay physicians for telephone consultations Promote professionalism and the patient—physician relationship, including physician responsibility to be prudent managers of resources Performance measures— if done right —have potential to assess physician performance, improve the quality of patient care, enhance the coordination and management of care, and reward physicians who meet or exceed the benchmarks set by performance measures.
However, if applied in a bureaucratic, arbitrary, or punitive manner, performance measurement can hinder quality and harm patient care, undermine the physician—patient relationship, and cause physician frustration and career dissatisfaction Demonstrating that they lead to patient care that is safer and more effective as the result of program implementation. Establishing or linking to technical assistance efforts and learning collaboratives so that all providers are motivated and helped to improve their performance.
Physicians have been forced to hire additional personnel to keep up with the abundant paperwork that insurance hassles create. All health insurance industry forms should be uniform, with one form per task rather than a different form for the same task from every insurer for example, a single durable medical equipment approval form and a single referral form. All health care plans and hospitals should use one standard physician credentialing and recredentialing form.
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Subscribe to Annals of Internal Medicine. Advanced Search. Position Papers 1 January Ginsburg, Robert B. Doherty, J. Fred Ralston Jr. Fleming, MD; Brian P.
Freeman, MD; Robert A. Nichols; Mark W. Purtle, MD; P. Weaver, MD; with contributions from David C. Abstract This position paper concerns improving health care in the United States. For most Americans, high-quality care generally is readily accessible without long waits but at high cost. However, the uninsured and, increasingly, the underinsured, the poor, and members of underserved minorities often have poor access to health care and poor health outcomes—in some cases worse than that of residents of developing countries.
The health workforce is well trained, yet the United States faces a severe shortage of primary care physicians. Most Americans— million But an estimated 47 million Americans Bureau of the Census 1. A survey by the Centers for Disease Control and Prevention found that However, as many as In addition, another 16 million people can be considered underinsured 4.
People without health insurance are much less likely than those with insurance to receive recommended preventive services and medications, are less likely to have access to regular care by a personal physician, and are less able to obtain needed health care services. Consequently, the uninsured are more likely to succumb to preventable illnesses, more likely to suffer complications from those illnesses, and more likely to die prematurely 5, 6.
Even among those with health insurance coverage, wide variations exist within the United States concerning cost, utilization, quality, and access to health care services 7, 8. Most of the variations among geographic areas are due to differences in the volume and intensity of practice that is, differences in the quantity of services provided per capita 7, 8. Yet, patients in high-intensity areas on average have outcomes that are no better, and perhaps worse, than those in geographic areas with lower rates of utilization 9, The Institute of Medicine has documented high levels of medical errors and inappropriate and unnecessary care, indicating system-wide problems with delivering consistently high-quality care 12, By , an estimated million Americans will have at least 1 chronic medical condition The U.
Disparities related to race, ethnicity, and socioeconomic status pervade the U. In addition to the large numbers of Americans who lack adequate health insurance, the cost, quality, and utilization of health care services vary widely. Meanwhile, the need for long-term care services and care coordination is increasing.
Preventive care, cross-discipline coordination, and proactive management of long-term care might reduce the cost of care, but these services often are uncovered or poorly reimbursed. Spending on health care in the United States has been rising at a faster pace than spending in the rest of the economy since the s Figure 1 . Figure 1. A minority of the population generate most health care costs.
People with large medical care costs are often chronically ill, disabled, or poor. Our society's inability to provide continuous, coherent patient-centered care for this group of individuals is one cause of the high aggregate cost of health care and contributes to the cost of public insurance programs. Patients who enter Medicare without previous insurance but with chronic illness will be sicker and more disabled and therefore more costly to that government program 5 , Health insurance premiums increased 8. The major components of U.
Table 1 shows comparable data for some of these key components for other countries. Figure 2. The nation's health dollar, calendar year where it went. Employer-based health insurance has been the basis for paying for health services since , but it is fast eroding under the pressure of relentlessly rising costs of care. The proportion of people with employer-based health insurance coverage dropped from Correspondingly, the percentage of people with government insurance, including Medicare, Medicaid, and military health care, increased from As health insurance premiums have risen, employers have reduced their costs by decreasing or dropping coverage or benefits, shifting to managed care plans, adopting pharmacy benefit management plans, and increasing the extent of cost sharing between employer and employee.
From to , the percentage of workers enrolled in employer-sponsored health plans that required cost-sharing of hospital bills increased from In , Copayments deter some insured people from obtaining needed care In addition, high health insurance costs deter employers who do not provide health insurance from buying coverage for their employees and make it nearly impossible for most uninsured people to buy more expensive individual policies on their own Despite the growing need for coordination of health care services, government and private insurers pay for health care services primarily on an episodic, visit-related basis with few, if any, incentives for providing comprehensive, coordinated, and continuous care for the prevention and management of chronic illness.
Unless changes are made in payment policy to compensate for these services, disincentives for care coordination will continue while the need will increase. Despite repeated attempts to rein in federal expenditures for Medicare and Medicaid, federal expenditures have continued to increase much faster than inflation in the entire economy Currently, approximately Medicare Part A reimburses hospitals for covered services for inpatient care.
It also reimburses skilled nursing facilities for covered services, but not for custodial or long-term care. It also covers hospice care and some home health care for qualified beneficiaries. The source of funding is primarily payroll contributions Federal Insurance Contributions Act from workers and employers to the Hospital Insurance Trust Fund. Medicare Part B covers medically necessary physician services; outpatient care; diagnostic and laboratory services; some supplies; and some services, such as care by physical and occupational therapists and some home health care not covered by Part A.
The other source of funding is the federal government from general revenues. The scale is indexed to rise with inflation. Medicare Part C provides an option Medicare Advantage for beneficiaries to enroll in private insurance plans that are approved to provide Medicare benefits. Medicare Advantage plans provide all Part A and Part B coverage and generally offer extra benefits or lower costs.
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Many include Part D drug coverage. These plans receive capitated payments from Medicare and often restrict covered services to provider networks, such as preferred-provider organizations, health maintenance organizations, and private fee-for-service plans. Under the traditional Medicare program, doctors, other providers, and suppliers receive payments according to schedules that set the maximum fees that Medicare will reimburse.
Beneficiaries in the original program—still by far the largest component of Medicare—must pay annual deductibles and co-insurance or copayments for covered services and supplies. In , Medicare prescription drug coverage became available as Medicare Part D. All Medicare beneficiaries are eligible to enroll in Part D. Coverage is provided through private insurance companies, and enrollment is voluntary.
Beneficiaries must pay monthly premiums. Previously, many Medicare beneficiaries purchased private supplemental insurance Medigap to obtain coverage for prescription drugs. However, following implementation of Medicare Part D, insurers are not offering new Medigap policies covering prescription drugs The Medicaid program provides medical benefits to over 52 million people who meet categorical eligibility standards.
The federal government establishes general guidelines for the program, but each state sets its own rules on eligibility and services. States may also offer additional coverage for optional services.
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The federal government and the states share responsibility for funding Medicaid. SCHIP was enacted in to expand health coverage for children in families with incomes that are low but above the level for Medicaid eligibility. By , about 4. SCHIP is jointly financed by the federal and state governments but is administered by the states. Disagreement between President Bush and Congress on funding and eligibility has led the President to veto legislation to reauthorize the program, and to date there have been insufficient votes in the House of Representatives to override a veto.
The Veterans Administration VA provides a range of benefits and services to about 5.
The VA is a single-payer system that may provide some important lessons for the rest of the U. The VA operates hospitals, nursing homes, 43 residential rehabilitation treatment centers, and community-based outpatient clinics. It is the nation's largest integrated direct health care delivery system. The VA facilities are affiliated with of the nation's medical schools and other health professions schools Veterans who are disabled because of a service-related injury or illness have first priority for access to VA health care.
Other veterans have access depending on annual discretionary appropriations by Congress. Funds are allocated to geographic regions that typically contain several hospitals. If funding runs out before the end of a fiscal year, services are curtailed. In the mids, the VA responded to criticism of deficiencies in VA health care by adopting a system-wide reorganization.
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Reforms included modernization of facilities, reorganization and decentralization, reduction of inpatient capacity, and reallocation of greater resources to ambulatory care.