Why we cannot agree on the direction of health reform: an exploration of American values

Most of the articles in this series examine historical forces that have shaped American health care policy. This article will ask the reader to step back from the swirl of events that have led to a health care system that provides excellent care to many and minimal services to a substantial minority. The purpose of this article is to place often contradictory health policies within their philosophical context. Such an analysis can lead to an understanding of the reasons for the simultaneous appearance of both competitive and regulatory features in the American health care system.     

Health‐Care Reform and ESI: Reconsidering the Relationship Between Employment and Health Insurance

The health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance (ESI). In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between investing in employee education and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives.     

What will future historians say about the Clinton health reform act

In a series of articles that began in the March-April 1992 issue of Physician Executive, the author has provided historical background on the debate that currently rages on the nature and course of national health reform. In addition to tracing past efforts to expand access to health care for Americans, Dr. Goldfield has provided unique insights into the American political process and into the American psyche. In this final article in the series, Dr. Goldfield provides his personal assessment of what the chances for real reform of the health care delivery system are and his views on what that reform will ultimately look like. He calls himself a skeptic, not a cynic, saying that the likelihood of meaningful change is small, given the numerous proponents of the status quo.     

Greening the health care supply chain: Triggers of change,models for success

A historic agreement signed in July 1998 between the American Hospital Association (AHA) and the U.S. Environmental Protection Agency (EPA) signals changes in waste management in the health care industry. The agreement, which calls for a fifty percent reduction of hospital waste by 2010, will not only have an impact on hospital facility managers, but throughout the entire healthcare supply chain. As this article argues, improving the environmental impact of the health care industry should start with the health care delivery institutions themselves. The health care industry has a long way to go in addressing its environmental impacts, compared to the energy and chemical industries, for example. One reason is that these industries are raising their suppliers' environmental performance. Health care delivery institutions can effectively pull environmental performance requirements through the entire supply chain as well. This can be accomplished by examining supply chain strategies of leading industries and firms and considering the role of environmental management systems such as a ISO 14001 throughout the entire chain.     

Elements of the American Health Security Act of 1993

Over the past several decades, there has been a plethora of proposals that were developed in response to the ongoing debate on how best to solve the problems of the American health care delivery system. In the past decade, calls for modification of our health system have become even more resonant, as measures to control rising costs were unsuccessful and access to basic services was diminished for many Americans. The most recent addition to the list of proposals for modifying the health care system is the American Health Security Act of 1993, introduced by President Clinton in September 1993. This article will examine the position of the Clinton Administration on health reform and the core elements of the reform package.     

Health care reform. Pan American Uni-Care Health Insurance Plan

Something is definitely wrong with the American health care system. Too many citizens are denied health care, and health care costs continue to rise at an uncomfortable and intolerable rate. Ensuring care for all is a paramount goal. There is no way to simultaneously cover everyone; leave the reimbursement of physicians unrestrained; ensure instantaneous access to every imaginable high-technology service; subsidize the world's costliest and least efficient health bureaucracy; and contain costs. Widespread dissatisfaction in all quarters--physicians, hospitals, third-party payers, regulators and consumers--has led to an avalanche of reform proposals. Rapidly changing social, political, and economic environments; rising fiscal pressure; and an evolving understanding of the major determinants of health have also created pressure for changes. There are some new and hopeful signs that America is facing up to the need for changes in the health care delivery system. The Pan American Uni-Care Health Plan that is described in this article may serve as a reasonable balance among these competing priorities.     

A new perspective on quality

The U.S. health care sector consumes nearly 13 percent of our nation's gross national product, $800 billion annually. Our nation allocates the highest amount per capita to health care in the world. Yet many measures of health care outcomes from these expenditures are inferior to other developed nations. The American health care system costs too much, excludes too many, fails too often, contains much excessive and inappropriate care, and knows too little about the effectiveness of the things it does. The purpose of this article is to discuss current payers' perspectives on the potential for quality improvement in the U.S. health care system.     

Health care fraud and abuse. What physician executives need to know

Fraud and abuse, which can occur in all industries, also exist in the health care industry. This problem is compounded by the reality that "American medicine, although undergoing evolution, now faces changes of a magnitude that has never before been encountered." These changes are creating new realities for physician executives and also new challenges. As there are changes in business practices, there will be changes in how fraud occurs in health care. Physician executives need to be sensitive to the possibility of fraud and abuse as an unwanted component in medical losses in managed care systems.     

Attracting qualified physicians to underserved areas. Part 2. Pay physicians more to practice in underserved areas.

With health networks searching for additional market share and with a projected 30.2 million to be enrolled in Medicaid HMOs by 2000, more health executives will be weighing various strategies of how to attract qualified physicians to practice in poor inner-city and rural areas. Most frequently cited as solutions are supplying more physicians, encouraging more medical school graduates to pursue primary care residencies, and modifying the number of international medical graduates entering U.S. residency programs. Part I of this article, which appeared in the November/December issue of The Physician Executive, reviewed the efficacy of these approaches. The second part explores a more pragmatic option: to simply improve the working conditions and pay substantially more to physicians who practice in "less desirable" locations. Although this idea is consistent with economic principles, drawbacks must be considered, such as: (1) the American taxpayers' reluctance to finance a more costly health care delivery system for the poor; (2) the inherent conceptual difficulties of a capitated Medicaid HMO serving as the linchpin for organizing, financing, and delivering care for the underserved; and, (3) many providers being expected to react in a fairly litigious manner to such an approach.     

Bringing baby home: a comprehensive case management program for obstetrical services

Originally presented to the Society of Home Health Care Management of the American College of Physician Executives at its November 16, 1993, meeting in Tucson, Ariz., the program described in this article was the winner of the College's 1994 Innovations Award in Medical Quality Management, sponsored by Merck Sharp & Dohme. The program shows the potential of case management for both improvement in the quality of care and containment of costs for a managed care population with a substantial Medicaid segment. This article is part of a continuing series on innovative programs in home health care.     

The Clinton health care proposal: reform squandered again!

Unlike the other articles in this series on efforts to reform the American health care system, this article is necessarily somewhat personal. I lived through it--not as a participant in the process but as a very interested bystander. To President Clinton's credit, his proposal was the first comprehensive proposal from a President since at least President Nixon and strictly speaking since President Truman. Yet, in the final analysis, the results were extremely depressing, not merely because of the obvious failure of the effort, but, even more important, because of the impact it has had on Americans' belief in the possibility for significant government role/responsibility in health care or, for that matter, in any significant domestic initiative. This article will trace portions of the failed Clinton health care initiative proposal--not the myriad other proposals that percolated through Congress. Realistically, only a proposal that had the support of the President had any chance of legislative success. This article will trace the development of the proposal and, while focusing on the universal coverage aspect, point to critical decisions that led to its legislative demise.     

Cutting to the chase: what physician executives need to know about HIPAA

All health care providers, plans, and clearinghouses will be affected by the federally mandated uniform standards for administrative transactions. This article presents distilled core information about the Health Insurance Portability and Accountability Act (HIPAA) legislation--the standards, penalties for violations, and status of final rules. It also raises several key unsolved issues of which clinicians, executives, and health care providers must be aware so they can prepare and plan for the upcoming changes. HIPAA is intended to improve the efficiency and effectiveness of the health care system, as well as to increase the protection and confidentiality of individually identifiable health information. The costs of making the transition to the legislated standards and processes remain a worrisome factor. Although there are two years before these standards must be implemented, and cost and compliance issues resolved, work has already begun in many health institutions to identify and address them.     

Defining the health care product to ensure quality and manage costs

The frenzy of health care reform activity now led by the Clinton Administration's American Health Security Act of 1993 might end in the worst of all possible outcomes: a new government entitlement program financed by business and a global budget. Unbridled entitlement could drive utilization of benefits to the maximum and, with a budget cap, guarantee rationing. So far, the administration has talked about expanding access and controlling costs--not about the health care product. Given the threat that change poses for vested interests, time will undoubtedly lapse before final implementation of a new system. Unless physicians involved in health management seize the opportunity during this window of opportunity to help shape the future of health care delivery, the likelihood of preserving the U.S. health care delivery system as we know it will be dim indeed.     

Newspapers foretell health care's future.

This article is based on a two-months snapshot (November 1998 to January 1999) of newspaper articles addressing various health care issues. Newspaper contents reflect the changing market share of competing societal concerns. Health care issues, particularly cost and choice, now preoccupy the American people. Health care trends percolate bottom-up through the pages of newspapers, not top-down from Washington, D.C, policymakers, or health care executives. By reviewing these articles, the author provides a big picture view of the prevailing and emerging health care trends. From the new thrust of consumerism and the public backlash against managed care organizations to the demise of HMOs and PPMCs, these observations signify not only the concerns that are bubbling to the surface but also the direction that health care is headed. Consumers are in the driver's seat and physician executives need to provide them with evidence of the value they desire--and understand what they perceive as value.     

The future of American health care in the "post-reform" era

"As the debate over health care reform rages in Washington, the market is reforming itself. For any given market, it's a question of 'How soon will it hit?', not 'Will it hit?'" Health care reform and market restructuring are ushering in a new era of integrated health care. Although the future is not fully clear, there are at least three competing models for the creation of regional and statewide health systems that will integrate the financing and delivery of services to large enrolled populations of consumers: Payer-driven networks. Provider-sponsored systems. Partnership models. Whatever the future scenario, physician executives will play a larger, more dominant role. Research on integrated health systems has identified three critical success factors for future success: physician-hospital integration, clinical integration and information integration. For managed care to be successful, there must be clinical leadership. The essence of managing care is clinical efficiency, based on "critical-path" treatment protocols and real-time patient care management, supported by integrated information systems.     

Reporting quality of health care to the board

The reporting of quality of health care to the governing board has long been an enigma. Now we are in the midst of a revolution in health care, as we shift our focus from solely the clinical performance of individuals to a broader scope of assessing and improving all activities around patient services and patient care--i.e., management outcomes integrated with clinical outcomes to help identify opportunities to improve patient care. In addition, apprised of corporate liability for the quality of care provided in health care organizations, governing boards are raising questions and demanding more information. To maintain this high degree of interest in quality of health care, information should be restricted to what the board needs to know. This article will be confined to the hospital's organizationwide quality system of monitoring and evaluating. While medical staff credentialing and privileging are also board responsibilities and quality management activities should be used in the privileging and credentialing process, they will not be addressed in this article.     

Executives share management tips

Members of the American College of Physician Executives were asked earlier this year to share their experiences in solving particularly nettlesome management problems. The goal was to construct a problem-solving tool for the widest possible array of problems in the full range of health care environments. This article is a distillation of the responses that were received, including contacts for further information on the problems and their solutions.     

Natural law and the "right to die"

Over the last two decades social concerns with the "right to die" have grown beyond the ability of our governmental and judicial institutions to consistently deal with them. One reason for this difficulty has been the unavailability of any legal or judicial standard that is consistent with American conceptions of liberty, morality, and justice. This article attempts to examine the theory of natural law to determine whether it may provide a consistent standard for resolving these difficult questions. As natural law theories are traced through history, they lead directly to the United States where a uniquely American interpretation became one of the foundational principles for our constitution. By applying these theories to the contemporary question of the "right to die," natural law can again provide the foundational principles needed to develop standards for dealing with such questions that are consistent with our historical, philosophical, and political traditions.     

Specialist versus primary care: not an easy question

The central focus in the debate to reform our nation's health care system is on cost, quality, and access. There is general agreement that there are too many specialists in the wrong places, which is said to contribute to the rising cost of health care. Physician profiling has supported the concept that some specialists are more costly than primary care physicians, although the severity of illness in patients treated by specialists may often be greater. Increasing the number of primary care providers may be a solution to reduce costs and will clearly improve access. The study reported in this article was carried out to examine the efficiency of primary care physicians and endocrinologists, a specialty that has been cited as one in which resource utilization is high, in caring for hospital inpatients with diabetic ketoacidosis.