There are a number of different healthcare reforms proposed during the Obama administration . Key reforms address costs and coverage and include obesity, prevention and treatment of chronic conditions, defensive treatment or tort reforms, incentives that reward more attention than better care, over-payment systems, tax policies, rationing, lack of doctors and nurses, interventions vs. hospice, fraud, and use of imaging technology, among others.
The first of the proposed reforms to be endorsed by the United States Congress is the Patient Protection and Affordable Care Act, which comes from the Senate and then passed by the House of Representatives in modified form on 21 March 2010 (with a vote of 219-212). President Obama signed the reform into law on March 23, 2010. Reuters and CNN summarize the reforms and the year in which they apply.
Video Health care reforms proposed during the Obama administration
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Various types of specific reforms have been suggested to improve the health care system of the United States. This ranges from increasing use of health care technology through changes to anti-trust rules that govern health insurance companies and law reforms to maintenance rationing. Different overall strategies have been suggested as well.
The Institute of Medicine reported in September 2012 that about $ 750 billion per year in US health care costs can be avoided or wasted. These include: unnecessary services ($ 210 billion per year); inefficient maintenance delivery ($ 130 billion); administrative overhead ($ 190 billion); price increases ($ 105 billion); prevention of failure ($ 55 billion), and fraud ($ 75 billion).
During a June 2009 speech, President Barack Obama outlined his strategy for reform. He mentioned electronic records, prevented expensive conditions, reduced obesity, refocused physician incentives from quantity of care to quality, bundling payments for treatment of conditions rather than special services, identified and communicated the most cost-effective treatments, and reduced defensive treatment.
President Obama further described his plans in a September 2009 speech to a joint session of Congress. The plan mentions: the neutrality of the deficit; does not permit insurance companies to discriminate under pre-existing conditions; limiting pocket expenditure; creation of insurance exchanges for individuals and small businesses; tax credits for individuals and small companies; independent commissions to identify fraud, waste and abuse; and malpractice reform projects, among other topics.
In November 2009, current Director of OMB Peter Orszag described aspects of the Obama administration's strategy during the interview: "To help withstand the long-term growth of Medicare and Medicaid costs, we need a new health care system that has already digitized information... where the information is used to assess what works and what is not smarter, and where we pay for quality over quantity while also encouraging prevention and well-being. "He also argues for bundling payments and responsible care organizations, which reward doctors for teamwork and patient outcomes.
Mayo Clinic President and CEO Denis Cortese has advocated an overall strategy to guide reform efforts. He argues that the United States has an opportunity to redesign its health care system and there is broad consensus that reforms are needed. He articulates the four "pillars" of such a strategy:
- Focus on value, which he defines as the ratio of quality of service provided relative to cost;
- Pay and align incentives with value;
- Cover everyone;
- Establish mechanisms to improve the health service delivery system over the long term, which is the primary means by which value will be increased.
Writing in The New Yorker, Atul Gawande's surgeon further distinguishes between delivery systems, which refers to how medical services are provided to patients, and payment systems, which refers to how payments for services are processed. He argues that shipping system reform is crucial to gaining controlled costs, but that reform of the payment system (eg, payment of government payments or private insurance) is less important but garnered a disproportionate share of attention. Gawande argues that dramatic improvements and savings in the delivery system will take "at least a decade." He recommends changes aimed at excessive use of health; refocusing incentives on value rather than profit; and comparative analysis of treatment costs across various health care providers to identify best practices. He believes this will be a recurrent empirical process and should be managed by "national agencies for health delivery" to analyze and communicate improvement opportunities.
A report published by the Commonwealth Fund in December 2007 examined 15 federal policy options and concluded that, if taken together, they have the potential to reduce future health care spending increases by $ 1.5 trillion over the next 10 years. These options include increased use of health information technology, research and incentives to improve medical decision making, reduce tobacco use and obesity, reform provider payments to boost efficiency, limit federal tax exemptions for health insurance premiums, and reform some market changes such as tribal redraw interest rate for the Medicare Advantage plan and allow the Department of Health and Human Services to negotiate drug prices. The authors base their modeling on the effect of incorporating these changes with the application of universal coverage. The authors conclude that there is no magic bullet to control the cost of health care, and that a multifaceted approach will be needed to achieve significant progress.
During February 2010, President Obama renewed his reform proposal, with modifications to the bill that had passed at that time.
Maps Health care reforms proposed during the Obama administration
Cost overview
Health spending accounted for 17.6% of GDP in the United States in 2010, down slightly from 2009 (17.7%) and is by far the highest share in the OECD, and eight percentage points higher than the OECD average of 9.5 %. After the United States was the Netherlands (on 12.0% of GDP), and France and Germany (both of which were 11.6% of GDP). The United States spends $ 8,233 on health per capita in 2010, two and a half times more than the OECD average of $ 3,268 (adjusted for purchasing power parity). Following the United States are Norway and Switzerland who spend more than $ 5,250 per capita. Americans spend more than double the relatively wealthy European countries such as France, Sweden, and Britain.
The annual rate of increase in cost slows down during 2010 and 2011. The reasons are debated, ranging from recession-related delay in visiting doctors for more long-term trends in moderating insurance premiums and reducing spending on structures and equipment.
The Medicare and Medicaid Service Centers report in 2013 that the annual rate of increase in health care costs has declined since 2002. However, per capita costs continue to increase. The per capita cost increase is an average of 5.4% every year since 2000. The relative cost to GDP has risen from 13.8% in 2000 to 17.9% in 2009, but remains at that level in 2010 and 2011.
Several studies have attempted to explain the reduction in annual rate of increase. The reasons include:
- Unemployment is higher because of the 2008-2012 recession, which limits the ability of consumers to purchase health care;
- Expired payments;
- Deductibles (the amount a person pays before insurance begins covering claims) has risen sharply. Workers must pay a greater share of their own health costs, and generally force them to spend less; and
- The proportion of workers with health insurance sponsored by companies listed in plans that require reductions can be increased to about three quarters in 2012 from about half in 2006.
Increased health costs also contribute to wage stagnation, as firms pay for benefits rather than wages. Bloomberg reported in January 2013: "If there is a consensus among health economists about anything, it is the health benefits that employers give out of wages If health insurance is cheaper, or the market is structured so most people buy health insurance for themselves rather than getting it with their work, people will be paid more and the salary increases will be higher. "
Best practices
Independent advisory panel
President Obama has proposed an "Independent Medicare Advisor Panel" (IMAC) to make recommendations on Medicare replacement policies and other reforms. Research on comparative effectiveness will be one of the tools used by IMAC. The IMAC concept is supported in the letter of some prominent health policy experts, as summarized by OMB Director Peter Orszag:
Their support of the IMAC proposal underscores what most serious health analysts have acknowledged for some time: moving to a health system that emphasizes quality over quantity will require sustained effort, and that the main goal of legislation is to place structures (such as IMAC) that facilitating change over time. And ultimately, with no on-site structures to help contain long-term health care costs when the health market evolves, nothing else we do in fiscal policy will matter much, because ultimately the rising cost of health care will burden the federal budget.
Both CEOs Mayo Clinic Denis Cortese and Surgeon/Author Atul Gawande argue that such panels will be critical for reforming the delivery system and increasing the value. Washington Post columnist David Ignatius also recommended that President Obama involve someone like Cortese to have a more active role in fostering reform efforts.
Comparative effectiveness research
Overutilization refers to when a patient too often uses a doctor or a doctor who orders more tests or services than is necessary to effectively address a particular condition. Some treatment alternatives may be available for certain medical conditions, at very different costs but no statistical difference in results. Such a scenario offers an opportunity to maintain or improve the quality of care, while significantly reducing costs, through research on comparative effectiveness. According to economist Peter A. Diamond and research cited by the Congressional Budget Office (CBO), health care costs per person in the US also vary greatly according to geography and medical centers, with little or no statistical difference in results. Research on comparative effectiveness has shown that significant cost reductions are possible. Former OMB Director Peter Orszag stated: "Nearly thirty percent of Medicare costs can be saved without negatively impacting health outcomes if spending in high- and middle-cost areas can be reduced to low-cost areas."
Pilot program
Gawande writes that Obamacare contains various pilot programs that may have significant impacts on cost and quality over the long term, although these are not taken into account in CBO cost estimates. He stated that these pilot programs cover almost every advocate's idea of ​​healthcare professionals, except for malpractice/tort reforms. He illustrates how the US faces cost problems with agriculture, with nearly 40% of household income absorbed by food costs in 1900. With the central supervision panel (USDA) and many pilot programs, the US can greatly increase the productivity of its food production and reduce this cost from time to time. He writes:
Medicare and Medicaid currently pay doctors the same amount regardless of the outcome. But there are pilot programs to increase payments for doctors who provide high quality care at a lower cost, while reducing payments for those who provide lower quality care at a higher cost. There are programs that will pay bonuses to the hospital that improve patient outcomes after heart failure, pneumonia, and surgery. There are programs that will impose financial penalties on institutions with high rates of infection transmitted by health workers. Others will examine the penalty system and rewards that are tailored to the quality of health care and rehabilitation at home. Other experiments try to move the drug away from the cost-for-service payment altogether. The bundled payment terms will pay the medical team only a thirty day fee for all outpatient and inpatient services related to, say, surgery. This will give the doctor an incentive to work together to smooth the treatment and reduce the complications. One pilot will go a step further, encouraging clinicians to join the "Accountable Care Organization" that is responsible for all their patients' needs, including prevention - so that fewer patients need surgery in the first place. These groups will be allowed to keep some of the savings they generate, as long as they meet the quality and service threshold. The bill has ideas for change in other parts of the system, as well. Several provisions seek to improve efficiency through administrative reform, by, for example, requiring insurance companies to create a standardized form for insurance reimbursement, to reduce the administrative burden on physicians. There are tests of various types of public health programs. The legislation also continues a stimulus package program that finances comparative effectiveness research - testing existing treatments for conditions against each other - as fewer treatment failures mean lower costs.
Prevention strategy
Increased use of preventive care (eg, regular doctor visits) is one way to reduce health care spending. The official budget value of universal health care proposals states that most of the savings are from providing preventive care to uninsured ones. Canadian doctors, who provide universal health care including preventive care, find that they can lower their total health care spending by 40% by simply promoting appropriate and inappropriate treatment precautions. An uninsured cancer patient diagnosed in stage four can spend more than half a million dollars in hospital bills within a few months, to be borne by all other health care consumers, when the same diagnosis in the first phase with preventive screening would be much cheaper. However, preventative care is usually given to many people who will never get sick, and for those who have fallen sick, it is partially offset by health care costs during the extra years of life.
Preventing obesity and overweight conditions provides a significant opportunity to reduce costs. The Center for Disease Control reports that about 9% of health care costs in 1998 were caused by overweight and obesity, or as much as $ 92.6 billion dollars in 2002. Almost half of this cost is paid by the government through Medicare or Medicaid. However, in 2008 the CDC estimates this cost to nearly double to $ 147 billion. The CDC identifies a series of expensive conditions that are more likely to occur due to obesity. CDC released a series of strategies to prevent obesity and being overweight, including: making healthier foods and drinks more available; supporting healthy food choices; encourage children to be more active; and create a safe community to support physical activity. An estimated 25.6% of US adults in 2007 were obese, compared with 23.9% in 2005. State obesity rates ranged from 18.7% to 30%. Obesity rates are almost the same among men and women. Some have proposed so-called "fat taxes" to provide incentives for healthier behavior, either by taxing products (such as soft drinks) that allegedly contribute to obesity, or to individuals based on body size, as they do. In Japan. A study released in October 2010 had the same cost estimate, of $ 168 billion, almost 17% of US medical costs. This is estimated at $ 2,400 per fat person. The study was conducted by researchers at Cornell University and Emory.
However, unlike the annual cost, the cost of a lifetime can be the highest among healthy people, who live longer. One study in the Netherlands shows that: "Until the age of 56 years, the highest annual healthcare cost for the obese and the lowest for healthy people." At older ages, the highest annual costs are excluded by the smoking group.But because of differences in life expectancy ( life expectancy at age 20 is 5 years less for the obese group, and 8 years less for the smoking group, compared with the healthy living group), the largest total lifetime healthcare cost for healthy people, the lowest for smokers, and the middle for fat people. "
Eliminate unnecessary tests
During April 2012, nine physician groups identified 45 commonly used tests but did not provide any proven benefit to patients or could actually be harmful. This is done at the urging of Dr. Howard Brody, who published this recommendation in the article 2010. The nine groups (the medical community) developed the list after months of analysis and review of medical literature by expert committees. The editorial board of the New York Times wrote: "Eliminating unnecessary care is not rationed.This is a healthy medicine and a healthy economy."
A July 2012 proposal suggests that health consumers always have "skin in the game" so that their costs increase as more services are provided.
Handle expensive chronic cases
CBO reported in May 2005: "Medicare spending is highly concentrated, with a small number of beneficiaries accounting for most of Medicare's annual expenditures.In 2001, 5 percent of the most expensive beneficiaries were listed in the cost-for-service Medicare (FFS) sector accounted for 43 percent of total expenditures, while the most expensive 25 percent... accounted for 85 percent of total expenditure... These high-cost recipients, compared with beneficiaries under 75 percent in terms of their spending, were slightly older, were more likely to suffer chronic conditions, such as coronary artery disease and diabetes, and more likely to die in a given year. "Such concentrations offer an opportunity to focus on major diseases and treatment approaches. Peter Orszag writes in May 2011: "The truth is that limiting future health care costs will require a variety of approaches, but in particular it means increasing information provided by providers about patients and their best practices, and the incentives provided by providers to deliver better care, especially in expensive cases. "
Market-based solutions
Privatize Medicare with coupon system
Rep. Paul Ryan (R) has proposed Roadmap for America's Future , which is a series of budgetary reforms. The January 2010 version of the plan includes a Medicare transition to a voucher system, which means the individual will receive a voucher that can be used to purchase health insurance in the private market. This will not affect those who are almost retired or currently enrolled in Medicare. A series of charts and charts that summarize the impact of the plan are included. Economists praised and criticized the special features of the plan. CBOs also partially print bills.
Medicaid recipients can also be given tax credits or subsidies to buy their own personal insurance, reducing the incentive for them to remain in the program.
Insurance company antitrust reform
Some conservatives advocate free market reforms such as breaking state monopolies on insurance and licensing and allowing consumers to purchase health insurance licensed by other countries.
GAO reported in 2002 (using 2000 data) the following statistics on insurance competition in the state market: "The average number of licensed operators in the small group market per country is 28, with a range from 4 in Hawaii to 77 in Indiana, the largest average carrier is about 33 percent, ranging from about 14 percent in Texas to about 89 percent in North Dakota The five largest operators, when combined, represent three-quarters or more markets in 19 of 34 countries supplying information, and they represent more than 90 percent in these seven states.25 Twenty-five of 37 countries supply information identifying Blue Cross and Blue Shield (BCBS) as the largest carrier offering health insurance in small group markets, and in all but one of the 12 remaining countries, BCBS carriers is one of the top five. The average market share of all BCBS operators in 34 states that supply information is about 34 percent, ranging from abo ut 3 percent in Vermont to about 89 percent in North Dakota; in these 9 countries the BCBS operator is combined for half or more of the market. "
GAO reported in 2008 (using 2007 data for the most part) the following statistics: "The average number of licensed operators in the small group market per country is 27. The average market share of the largest operators in the small group market is about 47 percent, with ranging from about 21 percent in Arizona to about 96 percent in Alabama.In 31 of the 39 states that supply market share information, the top operators have a market share of one-third or more.The group market, when combined, represents three-quarters or more of the market in 34 of the 39 countries that supply this information, and they represent 90 percent or more in 23 of these countries.30 Thirty six of the 44 states that supply information on top operators identify Blue Cross and Blue Shield operators as the largest operators, and in all but 1 of the remaining 8 states, the BCBS carrier is one of the five largest operators. ian of all BCBS operators in 38 states s upplying this information is about 51 percent, with a range of less than 5 percent in Vermont and Wisconsin and over 90 percent in Alabama and North Dakota... the median market share of all BCBS operators at 38 the country reported this information in 2008 about 51 percent, compared with 44 percent reported in 2005 and 34 percent reported in 2002 for the 34 states that supply information in each of these years. "
Economist Paul Krugman argues that letting the competition between nations create a "down race," in which "[t] he declares with the weakest rules - for example, those who allow insurance companies to refuse coverage to victims of domestic violence will set the standard for the nation as a whole The result is to suppress the suffering, to make the lives of Americans with existing conditions more difficult. "
Doctor incentive reform
Critics argue that the health care system has some incentives that drive expensive behavior. Two of them include:
- Doctors are usually paid for services provided rather than on salary. This provides financial incentives to increase the maintenance costs provided.
- Patients who are fully insured do not have financial incentives to minimize costs when choosing between alternatives. The overall effect is to increase insurance premiums for all.
Gawande argues: "Our cost-for-service system, distributing separate payments to everything and everyone involved in patient care, has all the wrong incentives: it rewards do more than do the right thing; it enhances the documents and duplicates the effort, and it makes doctors reluctant to work together for the best results. "
Gawande quoted a surgeon as saying: "We made a wrong turn when the doctor stopped being a doctor and became an entrepreneur." Gawande identifies various income-generating and profit-based incentive approaches that doctors use in high-cost areas that may have led to excessive healthcare utilization. He compared this to low-cost areas that employ paid doctors and other techniques for value appreciation, referring to this as "a battle for the soul of American medicine."
One option involves a series of integrated health care providers that charge patients a premium or flat fee to participate in the network, rather than the cost for each individual service. This modifies the physician's incentives from ordering more services to solve problems efficiently (ie, more care for more cost-effective treatments). The provider network will also buy insurance for disaster cases (very high cost).
Cost of medical malpractice liability and lawsuit reform
Critics argue that the cost of medical malpractice (insurance and lawsuits, for example) is significant and should be addressed through tort reform.
How much this cost is a matter of debate. Some argue that malpractice lawsuits are a major driver of medical costs. The 2005 study estimated the cost of about 0.2%, and in 2009 the insurance company WellPoint Inc. said "liability does not encourage premiums." A 2006 study found neurologists in the United States ordered more tests in a proposed theoretical clinical situation than their German counterparts; US doctors are more likely to be afraid of litigation that may be caused by the teaching of defensive strategies reported more frequently in US teaching programs. Calculating both direct and indirect costs, other studies estimate the total "related to" malpractice costs between 5% and 10% of total US medical costs.
The 2004 report by the Congressional Budget Office puts medical malpractice costs at 2 percent of US health spending and "even significant reductions" will do little to reduce the growth of health care costs. The 2009 CBO report estimates that approximately $ 54 billion may be retained for ten years by limiting medical malpractice lawsuits. The lawsuit reform package that includes the jury award limit of $ 500,000 for compensation and $ 250,000 for "pain and suffering" losses will lower the insurance premium to about 10 percent.
In August 2009, doctors and former Chairman of the Democratic National Committee Howard Dean explained why the lawsuit reform was ignored from the Congressional healthcare reform bill then under consideration: "When you pass such a huge bill, the more stuff you put into it. , the more enemies you make, right?... And the reason tort reform is not in the bill is because the people who wrote it did not want to take trial lawyers alongside others they captured, plain and simple truths. "
Others argue that even successful tort reform may not lead to lower aggregate responsibilities. For example, the contingent cost system currently skits litigation against high-value cases while ignoring the meritorious minor cases; aligning litigation closer to achievement may increase the number of small rewards, offsetting the reduction in great rewards. A study in New York found that only 1.5% of hospital negligence led to claims; In addition, CBOs observed that "healthcare providers are generally not exposed to the financial costs of their own malpractice risk because they carry insurance coverage, and the insurance premium does not reflect the record or practice style of each provider but more common factors such as location and medical specialization. "Given that total liabilities are relatively small compared to the number of physicians who pay for malpractice insurance premiums, alternative mechanisms have been proposed to reform malpractice insurance.
In 2004, the CBO studied restrictions on malpractice decisions filed by the George W. Bush Administration and members of Congress; The CBO concludes that "the available evidence to date does not make a strong case that limits malpractice responsibility will have a significant effect, either positive or negative, on economic efficiency." Empirical data and reporting have shown that some of the highest medical costs are now in countries where tort reform has led to malpractice premiums and lawsuits declining dramatically; unnecessary and detrimental procedures are caused by the system "are often encouraged to maximize revenue on the patient's needs."
One of the proposed options includes a special health care court rather than a jury system. Such a tribunal is in another discipline. In an administrative health court, an expert judge will decide the case based on best medical practice, writing an opinion subject to an appeal to an appeal court. There will also be full disclosure requirements by the hospital, and all the facts will be put back into the health care system so providers learn from their mistakes. Such an approach has been opposed by the court's lawyers.
Overcoming lack of doctors and nurses
The United States is facing a shortage of doctors and nurses projected to deteriorate as Americans, who can raise the price of these services. Writing at the Washington Post, cardiologist Arthur Feldman cites studies showing the United States is facing a "critical" shortage of doctors, including about 1,300 general surgeons in 2010.
The American Family Physician Academy predicts a shortage of 40,000 primary care physicians (including family practice, internal medicine, pediatrics and obstetrics/gynecology) by 2020. The number of medical students who choose primary care specialization has dropped 52% since 1997. Currently, only 2% a medical school that chooses primary care as a career. The amendment to the Senate health bill covers $ 2 billion in funds over 10 years to create 2,000 new residency training slots geared for primary care and general surgery care. Writing in Forbes, a doctor argues that this is a "small band aid at best," advocates full loan repayment and secured positions after graduation.
The doctor wrote the NYT Op Ed in May 2011 stating that doctors usually graduate with an average of $ 155,000 in debt from medical schools, with more than 80% due to debts of some kind. This encourages some doctors to specialize in higher payments than primary care. As specialists, they prescribe more expensive treatments. Around $ 2.5 billion/year will be required to make the school of Medicine free, which the authors estimate is one-thousandth of the total annual health care cost. Creating a free medical school will help overcome the shortcomings in their view.
The US had 2.3 doctors per 1,000 people in 2002, ranked 52nd. Germany and France have about 3.4 and rank in the top 25. The average OECD in 2008 was 3.1 doctors per 1,000 people, while the US had 2.4.
The American Association of Colleges of Nurses cites research that estimates that registered nurse shortages will reach 230,000 by 2025 during American age, with more than 135,000 open positions during 2007. An additional 30% more nurses must pass each year to meet demand. A study by Price Waterhouse advances several strategies to address the shortage of nursing, including developing public-private partnerships, federal and state grants for nursing students and educators, creating a healthy work environment, using technology as a training tool, and designing more flexible roles for nursing follow-up practices given their increased use as primary care providers.
Newsweek writes: "Recently, some policymakers have argued that instead of having primary care physicians, more people - especially young, healthy patients with modest medical needs - should see a nurse or physician assistant which regulates routine care and kicks more complicated problems to the doctor when they appear.'If you have just come to check your blood pressure and your pulse is taken, you really do not need to see a doctor, and you may not need to see a nurse, "said David Barrett, president and CEO of Lahey Clinic in Burlington, Mass." There are three-line military sergeants with a two-year degree that can provide excellent primary care.There is absolutely no reason to force all primary care providers to have MD titles "
Tax reform
The Congressional Budget Office has described how tax treatment of insurance premiums can influence behavior:
One of the factors that perpetuate inefficiencies in health care is the lack of clarity about the cost of health insurance and who is covering the costs, especially occupational health insurance. Employer payments for employment-based health insurance and almost all payments by employees for such insurance are exempt from individual income and payroll taxes. Although theory and evidence show that workers ultimately finance their job-based insurance through lower home wages, unproven costs for many workers... If transparency increases and workers see how much their income is reduced for employers' contributions and what contributions they pay , there may be a wider change in cost consciousness that shifts demand.
Peter Singer wrote in the New York Times that the current exclusion of insurance premiums from compensation represents a $ 200 billion subsidy for the private insurance industry and is unlikely to happen without it. In November 2009, The Economist estimated that the tax provided by the employer's health insurance (currently exempt from tax) would add $ 215 billion per year to federal income taxes.
The health insurance provided by the employer receives tax benefits that have not been closed. According to the OECD, it "encourages the purchase of more generous insurance plans, especially plans with little cost sharing, thus exacerbating moral hazard". Consumers want unlimited access to medical services; they also prefer to pay through insurance or taxes rather than getting out of the bag. These two needs create cost-efficiency challenges for health care. Some studies have found no consistent and systematic relationship between types of health care financing and cost control.
Some have proposed "excise taxes" for 'high cost' Cadillac insurance plans. A study published in Health Affairs in December 2009 found that high-cost health plans did not provide extraordinarily rich benefits to applicants. The researchers found that only 3.7% of variation in family insurance costs in an employer sponsored health plan was caused by differences in actuarial benefit value. Only 6.1% variations can be attributed to a combination of design benefits and plan types (eg, PPO, HMO, etc.). Employers' industries and regional variations in health care costs explain some variations, but most can not be explained. The researchers concluded, ".. That analysts should not equate high-cost plans with Cadillac plans,.. [W] without proper adjustments, simple hats can worsen rather than correct the current injustice"
A premium tax subsidy to help individuals purchase their own health insurance has also been suggested as a way to increase coverage rates. Research confirms that consumers in the individual health insurance market are price sensitive. It seems that price sensitivity varies among the population sub-groups and is generally higher for younger individuals and lower-income individuals. However, research also suggests that subsidizing alone is unlikely to solve uninsured problems in the US.
Government actions
Overcome Medicare scams
The Government Accountability Office listed Medicare as a "high-risk" government program because of its vulnerability to improper payments. Estimated Medicare scams or "improper payments" vary. The Office of Management and Budget reports that $ 54 billion in "improper payments" was made for Medicare ($ 24B), Medicaid ($ 18B) and Medicaid Advantage ($ 12B) during FY2009. This is 9.4% of the $ 573 billion spent in this category. GAO reported in 2000: "The Office of the Inspector General of the Department of Health and Human Services has reported that payment of medical service payments of $ 13.5 billion for fiscal year 1999 payments may have been paid unduely for reasons ranging from accidental errors to direct fraud and abuse. "Less than 5% of Medicare's claims are audited. The CBO reported in October 2014 that it is difficult to measure health service fraud associated with government programs. CBO reports that: "According to HHS, since 2009 the HEAT Medicare task force has filed criminal and civil charges against more than 1,700 defendants falsely charging Medicare programs worth more than $ 5.5 billion." However, fake billing is part of the fraud, as most are undetectable.
According to CBS News, Medicare's fraud accounts for about $ 60 billion Medicare payments annually, and "has become one of, if not the most lucrative crimes, in America." Criminals set up fake companies, then charge Medicare for fraudulent services provided to valid Medicare patients who never received service. These costs appear on Medicare reports provided to Medicare card holders. The program pays more than $ 430 billion per year through more than 1 billion claims, making enforcement challenging. The enforcement budget is "very limited" according to one Medicare officer. US Attorney General Eric Holder said in an interview: "Clearly more audits need to be done and need to be done in real time." The Obama administration provides Medicare with an additional $ 200 million to fight fraud as part of its stimulus package, and billions of dollars to computerize medical records and improve networks, which should help Medicare in identifying fraudulent claims.
During July 2010, President Obama signed the Law on Elimination of Inappropriate Payments and the Recovery Act of 2010, citing approximately $ 110 billion in unauthorized payments of all types, including Medicare and Medicaid. President Obama has directed his administration to reduce this payment by $ 50 million annually in 2012, less than 1%.
Coverage mandate
Reforming or restructuring private health insurance markets is often recommended as a means to achieve health care reform in the US. Insurance market reforms have the potential to increase the number of Americans with insurance, but it is not possible to significantly reduce the rate of growth in health care. spending. Careful consideration of basic insurance principles is important when considering the insurance market reforms, to avoid unforeseen consequences and ensure the long-term viability of the reformed system. According to a study by the Urban Institute, if not systematically implemented with appropriate protection, market reforms have the potential to cause more problems than they solve.
Since most Americans with personal coverage accept it through a company-sponsored plan, many advise employers to "pay or play" terms as a way to increase coverage levels (ie, employers who do not provide insurance should pay taxes instead). However, research shows that current payments or proposals play limited in their ability to increase coverage among working poor. This proposal generally excludes small companies, does not distinguish between individuals who have access to other forms of coverage and those who do not, and increase the overall compensation costs to employers.
In October 2009, the Wall Street Journal reported that while the requirement to purchase health insurance was central to both DPR and Senate proposals, this mandate of coverage "was burned from both ends of the political spectrum, with some liberals saying the punishment was too harsh, for those who refused and conservatives denounce the whole concept. "However, according to the article," [h] a security policy expert... there might be a good reason for that mandate. " The proposed reforms will prohibit health insurance companies from denying coverage to individuals with pre-existing medical conditions. Insurers say that, in order to keep premiums from rising for everyone, it is important for a healthy person to pay into the insurance pool to balance the costs of the individual at a higher cost.
Arguing by requiring individuals to purchase coverage, the Cato Institute has reiterated that Massachusetts's law forcing everyone to buy insurance has raised costs: "Premiums grow 21 to 46 percent faster than the national average, in part because the mandates of Massachusetts individuals have effectively prohibited, affordable health plan. "They say that" the mandate gives politicians enormous power to dictate the content of any American health plan - a force that surely will be captured and used by healthcare providers to raise the required level of insurance "and certify that providers the service succeeded in persuading legislators to include an additional 16 mandate benefits in the required benefit package for the first three years after the coverage mandate was enacted. They also said that by prohibiting the use of health status in pricing, Massachusetts legislation "further increases the premium for young and healthy" and, as a result of bad selection, encourages a more comprehensive health plan out of the market. The conclusion they get is that "[T] he most sweeping provisions... is the 'mandate of the individual' that makes compulsory health insurance Massachusetts suggests that such a mandate would expel millions of people from low-cost health plans and force them to pay more premiums high. "
Writing on the New York Times public opinion blog "Room for Debate" single-paying health care lawyer Marcia Angell, former editor-in-chief of the New England Journal of Medicine, said that the coverage mandate will not be needed in a single pay-system and even in the context of the current system he " disturbed by the idea of ​​an individual's mandate. " He described the Massachusetts mandate as a "fortune for the insurance industry" and wrote, "The premiums rise much faster than income, the smaller benefit packages, and the deductibles and co-payments will go up."
In April 2009, the Boston Globe reported that the number of people seeking emergency room treatment and emergency room visit costs increased after the 2006 mandate came into force (comparing 2005 to 2007). The number of visits increased 7% during the period, while costs rose 17%. State officials have warned that it is too early to determine whether the country's new coverage mandate has failed to reduce the use of emergency rooms, but some doctors and policymakers say it is unlikely that the coverage mandate alone could solve the problem of emergency room crowds and overuse. In August 2009, the Boston Globe reported that Massachusetts had "the most expensive family health insurance premium in the country." Premiums in Massachusetts increased by 40 percent from 2003 to 2008, compared with a national average increase of 33 percent. The report has not broken the number of increases since 2006, but since Massachusetts reform is often taken as a model for national reform, "advocates on various sides of the issue say the report underscores the urgency of including cost control across any major federal or state scale improvement." Karen Davenport, health policy at the Center for American Progress, argues that "before making compulsory coverage, we need to reform the health insurance market, strengthen public health insurance programs, and finance premium subsidies for people who can not afford their own coverage."
Addressing the issue when it was proposed in 1994, the CBO wrote: "The mandate that requires all individuals to purchase health insurance will be an unprecedented form of federal action.The government never requires people to buy goods or services as legitimate conditions of residence. United States of America." There is also disagreement over whether federal mandates will be constitutional, and state initiatives opposed to federal mandates may lead to litigation and delays.
On June 28, 2012, the US Supreme Court upheld the provisions of the individual mandate as the Constitution.
Rationing care
President Barack Obama believes that US health care is rationed, based on income, occupation, and pre-existing medical conditions, with nearly 46 million uninsured people. He argues that millions of Americans are denied coverage or face higher premiums as a result of pre-existing medical conditions.
Peter Singer and David Leonhardt each have separately noted that rationing health care is not an option, but an economic necessity. All health care resources are limited and should be allocated in several ways or other. The problem is the most sensible way to do it.
Former Republican Trade Secretary Peter G. Peterson also argues that some sort of allotment is unavoidable and desirable given the US financial situation and trillions of dollars of unfunded Medicare obligations. He estimates that 25-33% of healthcare is provided to them in the last months or years of life and advocates restrictions in cases where quality of life can not be improved. He also recommends that budgets be made for government healthcare costs, through setting spending limits and pay-as-you-go rules that require a tax increase for each additional expense. He has indicated that a combination of tax increases and spending cuts will be necessary. All these issues will be addressed under the supervision of the fiscal reform commission.
Rationing by price means accepting that there is no triage as needed. Thus in the private sector it is accepted that some people get expensive surgeries like liver transplants or non life-threatening ones such as cosmetic surgery, while others fail to get cheaper and far more effective treatments such as prenatal care, which can save the lives of many fetuses and children. newborn child. Some places, such as Oregon for example, do explicitly ration Medicaid sources using medical priorities.
Politicians on the right tend to be afraid of democratically elected governments becoming involved in racial decision making. Former House Speaker Newt Gingrich (R-GA) argues that the Obama-backed reform plan extends government control over health care decisions, which he calls the type of health care rationing. Senator Charles Grassley (R-IA) made a similar argument claiming for example that men such as late Sen. Edward Kennedy received health care in the US to be rejected in countries that have state-controlled healthcare, the claim that The Economist The magazine said it was "dangerous" and went on to say that "The reality is that America, like Britain, has already used extensive allotment.
Better use of health care technology
Automation of patient records
The Congressional Budget Office has concluded that the increased use of health information technology has the potential to significantly reduce overall health care spending and realize a major improvement in the quality of health care provided that the system is integrated. The use of IT health in an unintegrated setting will not realize all the projected savings.
Registry treatments
One application of health care technology is the creation of a record or database to link treatment to outcomes. Useful, identifiable and less useful treatments can be avoided to reduce costs.
Payment system update
The payment system refers to billing and payment for medical services, which is different from the delivery system through the services provided. More than 1,300 US health insurance companies have different forms and processes for billing and reimbursement, which cost a lot of money from service providers (especially doctors and hospitals) to process payments. For example, the Cleveland Clinic, which is considered a low-cost, best practice hospital system, has 1,400 scribes to support 2,000 physicians. Furthermore, insurance companies have their own overhead and profit margin functions, many of which can be eliminated by a single paying system. Economist Paul Krugman estimates in 2005 that transforming from the current private insurance system into a single paying system will allow $ 200 billion per year in cost savings, primarily through insurance company fees. One advocacy group estimates savings of as high as $ 400 billion a year for 2009 and beyond.
Supporters of health care reforms argue that moving to a single payer system will reallocate the money currently spent on administrative costs necessary to run hundreds of insurance companies in the US to provide universal care. A study frequently cited by Harvard Medical School and the Canadian Institute for Health Information provides that about 31 percent of US health care dollars, or more than $ 1,000 per person per year, go to health care administration costs. The other estimates are lower. One study of bills and related insurance (BIR) costs are borne not only by insurance companies but also by doctors and hospitals finding that BIRs among insurance, doctors, and hospitals in California represent 20-22% of personal insured expenditures in California acute care setting.
The "single payer" advocates argue that shifting the US to a single paying healthcare system will provide universal coverage, provide patients free choice of providers and hospitals, and ensure comprehensive coverage and equal access to all necessary medical procedures, without increasing overall spending. The shift to a single paying system, with this view, will also eliminate oversight by the managed care reviewers, restoring the traditional doctor-patient relationship. Among organizations that support single-payer health care in the US is the Doctor for the National Health Program (PNHP), an organization of about 17,000 American doctors, medical students, and health professionals.
Reduce the cost of imaging technology
During 2009, Medicare spent $ 11.7 billion on medical imaging, such as CT scans and MRI. From 2005 to 2009, the use of scans grew at an annual rate of 14%, but may have slowed since due to a combination of changes in incentives and saturation of use. Initially, demanding the patient insist on a scan; doctors are afraid of wearing malpractice if they refuse; and doctors and hospitals want to maximize revenue. One study shows that changing incentives may have reduced cost growth. From 2006 to 2010, the share of workers with deductibles exceeding $ 1,000 grew from 10 percent to 27 percent. The rising costs outside the pocket have made patients and doctors more cost conscious. Furthermore, a combination of prior notification, higher patient joint payments and controlled reimbursement of costs may have contributed to a slowdown in cost growth.
Motivation
International health comparison has found that the United States spends more per capita than other developed countries but falls under similar countries in various health metrics, indicating inefficiency and waste. In addition, the United States has significant undernurance and significant non-revenue liabilities from its aging demographic and its social insurance program Medicare and Medicaid (Medicaid provides free long-term care to poor parents). The fiscal and human impacts of these problems have motivated the reform proposals.
According to World Bank statistics 2009, the US has the highest cost of health care compared to the size of the economy (GDP) in the world, although an estimated 50.2 million people (about 15.6% of the estimated population in September 2011 of 312 million) have no insurance. In March 2010, billionaire Warren Buffett commented that the high costs paid by US companies for the health care of their employees put them in an unfavorable position.
Furthermore, an estimated 77 million Baby Boomers reaching retirement age, combined with a significant annual increase in health care costs per person will place enormous budgetary burdens on US state and federal governments, primarily through Medicare and Medicaid spending (Medicaid provides care long term for poor parents). Maintaining the US federal government's long-term fiscal health is significantly dependent on controlled health care costs.
Cost and availability of insurance
In addition, the number of entrepreneurs offering health insurance has declined and the costs for health insurance paid by employers increased: from 2001 to 2007, the premium for family coverage increased 78%, while wages rose 19% and prices rose 17%, according to the Foundation The Kaiser family. Even for those employed, private insurance in the US varies greatly in scope; one study by the Commonwealth Fund published in Health Affairs estimated that 16 million US adults were under-guar- anted in 2003. Those less well-assured were significantly more likely than those with adequate insurance to forget health care, reporting financial pressures due to bills medical, and experiencing coverage gaps for items such as prescription drugs. The study found that underinsurance disproportionately affected those with low incomes - 73% of underinsured in the study population had annual revenues below 200% of federal poverty rates. However, a study published by the Kaiser Family Foundation in 2008 found that the plans of employers' service provider organizations (PPOs) in larger companies in 2007 were more generous than the Medicare or Standard Option of the Federal Employee Health Benefit Program. One indicator of the consequences of inconsistent healthcare coverage in the United States is a study in Health Affairs that concludes that half of personal bankruptcies are involved in medical bills, although other sources deny this.
There are health losses due to inadequate health insurance. A 2009 study found more than 44,800 excess deaths annually in the United States because Americans lack health insurance. More broadly, the estimated number of people in the United States, both insured and uninsured, who died from lack of medical care was estimated in the 1997 analysis to nearly 100,000 per year. A study of the effects of Massachusetts universal health law (enacted in 2006) found a 3% reduction in mortality among people aged 20-64 years - 1 death per 830 people with insurance. Other studies, just as those who examined the random distribution of Medicaid insurance to low-income people in Oregon in 2008, found no change in mortality rates.
Insurance costs have been a major motivation in reforming the US health care system, and many different explanations have been raised on the grounds of high insurance costs and how to improve them. One criticism and motivation for health care reform is the development of the medical industry complex. This is related to the moral argument for health care reform, framing health as social goodness, which is essentially immoral to be rejected by people on the basis of economic status. The motivation behind health reform in response to the medical industry complex also stems from the issue of social injustice, the promotion of drugs over preventive care. The medical industry complex, defined as a network of health insurance companies, pharmaceutical companies, and the like, plays a role in the complexity of the US insurance market and the thin line between government and industry in it. Similarly, the criticism of the insurance market undertaken under the capitalistic free market model also includes that medical solutions, as opposed to preventive health care measures, are promoted to maintain this complex medical industry. The arguments for a market-based approach to health insurance include the Grossman model, which is based on the ideal competition model, but others have criticized this, arguing that in essence, this means that people at higher socioeconomic levels will receive quality healthcare better.
Uninsured rate
Another concern is the level of uninsured people in the US. In June 2014, Gallup-Healthways Well-Being conducted a survey and found that uninsured rates were down. 13.4 percent of US adults are not insured in 2014. This is a decline from a percentage of 17.1 percent in January 2014 and translates to about 10 million to 11 million people who get coverage. The survey also looked at the major demographic groups and found each of them progressing in obtaining health insurance. However, Hispanics, who have the highest uninsured rates of any race or ethnic group, lag behind in their progress. Under the new health care reform, the Latins are expected to be the main beneficiaries of the new health care legislation. Gallup found that the biggest drop in the uninsured rate (2.8 percentage points) was among households earning less than $ 36,000 per year.
Waste and fraud
In December 2011 Administrators left the Medicare Center & amp; Medicaid services, Donald Berwick, assert that 20% to 30% of health care spending is waste. He listed five causes of waste: (1) patient overtreatment, (2) failure to coordinate care, (3) administrative complexity of health care system, (4)
Source of the article : Wikipedia
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