25 Health care trends. What's hot,what's not,and what does the future hold

As we usher in 2003, America's health care system remains in a chaotic state. Will managed care live or die? Will quality improvement efforts pay off? Are we ready for the next bioterrorism attack? Will the shortage of physician soon rival the shortage of nurses? To help gauge where health care stands today and what the future holds, The Physician Executive asked doctors who serve on ACPE's peer review panel to list the hottest health care trends in the U.S right now. Then, we took the list to three respected health care futurists -- Leland Kaiser, PhD, Jeff Goldsmith, PhD, and Russel Coile, MBA -- and asked them for their insights on the trends. Yes, Kaiser, Goldsmith and Coile are opinionated. Yes, they're controversial. But no matter whether you agree or disagree with their views, the three health care futurists' comments could spark discussions that will help shape U.S. health care this year and beyond. The trends are presented in no particular order.     

A national perspective on UR (utilization review)

Quality of care is the responsibility of each and every attending physician. There are many definitions of quality, none of which encompasses the universe of medical practice. Care that is neither medically necessary nor appropriate can never be considered good, no matter who renders it or how good the outcome. It is upon these premises that utilization review firms focus.     

Promising, and delivering, health care value

It came as no surprise a year or so ago to read in Physician Executive that "Clinical decision-making is no longer the exclusive domain of the health care practitioner." The authors pointed out that consumers, as patients and as business-payers, are insisting on provider accountability, both in quality and in appropriate cost. They used the phrase "health care value" to show a balance between cost containment and quality. One managed care operation has decided to operate on the premise of health care value.     

Information technology, Part 3. The technology hierarchy

The era of the networked society--and medical care depending on networked intelligence--is dawning. Physicians need to plan for office practice information systems in common, with an eye to conveying data electronically between all the locations of care and all the providers involved in caring for defined populations of people. The shared database will become the most important asset of the collection of providers who make up the delivery system that creates it. This will be accomplished by layering technology on local and wide-area networks of group practices, hospitals, health plans, and payers and developing standards that make data accessible in the same format to all users, no matter where they are.     

Equitable Taxation and the Provision of Health Insurance Subsidies

Current U.S. income tax laws allow many taxpayers to exclude from taxable income part or all of the cost of acquiring health insurance through an employer‐sponsored benefit plan. This favorable tax treatment generally applies regardless of whether the employer or employee actually pays the health insurance premiums. We describe the effects of this tax policy on the U.S. tax system's horizontal and vertical equity. We also explain how taxpayers covered by employer‐sponsored plans are significantly subsidized by the government in acquiring health insurance, whereas taxpayers who acquire health insurance by other means or who are not covered by health insurance at all receive no such government assistance. We conclude that any prospective health‐care policy initiatives, including modifications to the 2010 health‐care reforms, should contemplate both the horizontal and vertical equity of the tax treatment of health insurance premiums.     

Why such a hurry?

Over the past decade or so, federal health policy has chased health care costs that grew out of control largely because of federal intervention in the form of the Medicare/Medicaid programs. Having implemented a prospective pricing system for institutional providers, the government has followed up with a resource-based relative value system for physicians. The prognosis for this new effort may be no better than that for past attacks on health care costs, and the outcome could be substantially worse.     

Informal Caregiving and Women's Work Choices: Lessons from the Netherlands

This paper focuses on the effects of Dutch long‐term care and labour market policies on women's labour market participation and informal caregiving decisions. Labour market participation and informal caregiving are estimated jointly through a multivariate dynamic binary probit on European Community Household Panel data. Under Dutch policy, informal care decisions appear to be independent of household non‐labour income and no significant impediment seems to hinder the contemporaneous practice of work activities and care. However, past informal care provision still slightly reduces the probability of currently working and vice versa, leaving room for policy improvements to enhance labour market participation.     

Patient care: past, present, and future

The 40 years since St Christopher's Hospice opened has witnessed a burgeoning international interest in palliative care. Its key characteristics comprise a focus on the whole-person (physical, psychological, social, and spiritual), patient-centeredness (partnership with and empowerment of the patient and family), openness and honesty in communication, an acceptance of the inevitability of death coupled with improvement in the quality of life, multi-professional teamwork integrated with community (volunteer) involvement. Although much has been achieved, much remains to be done. Both in resource-poor countries and in more wealthy ones, the scope of palliative care has changed. Initially in the United Kingdom, palliative care was mostly limited to cancer patients but now strenuous efforts are being made to extend coverage to other patient groups, e.g., those with end-stage heart disease or renal failure. In India, with a dearth of chronic care facilities, palliative care services increasingly embrace those with chronic disability as well as progressive end-stage disease. In Sub-Saharan Africa, the devastating impact of AIDS is having a major impact on the development and delivery of palliative care. To maximize the benefits of limited financial and other resources, a strategic approach is necessary. The World Health Organization emphasizes three essential foundation measures: health service policy, public awareness and professional education, and drug availability. However, at the end of the day, if we are truly to honor Cicely Saunders, palliative care must remain a movement with momentum, combining creative charisma with inevitable bureaucratic routinization.     

Meta-analysis: apples and oranges, or fruitless

Meta-analysis is an impressive tool for systematic synthesis of health care management and policy research findings. Used wisely, it can impose an appealing order on the chaos of a large body of evidence. Occasionally, it can even contribute to resolution of a clinical controversy. However, the technique is currently in a state of evolution. Until it is further refined and standardized, its consumers must be mindful of its limitations and use meta-analytic reviews with care.     

Managed care liability.

Debate is heating up concerning proposals that patients have the right to sue their managed care plans for damages from wrongful denial of benefits or delays in care. Some states have recently passed legislation to address this issue and it is expected to be an area of intense legislative debate during this year. As managed care entities increasingly enter the realm of medical decision-making, the additional burden of this responsibility is taking shape. Whether managed care plans should be treated like providers of care and be held accountable for decisions that impact patient outcomes, or be viewed only as insurers is a policy question of immense proportion.     

Cost-effectiveness and coverage policy.

Cost-effectiveness analyses have become a pervasive element of health care. But they have not had a major impact on medical coverage policy. The challenge of implementing cost-effectiveness as a medical coverage criterion is related to the following issues: (1) Contract language does not include cost-effectiveness as a coverage criterion; (2) cost-effectiveness analyses often take the societal, population-based perspective, while health care is delivered on an individual basis; (3) there is no standard methodology for cost-effective analysis; (4) there is no explicit cut-off between cost-effective and cost-ineffective; and (5) cost-effectiveness analyses are not time sensitive.     

政策方向、经济周期与货币政策效力非对称性

货币政策在治理1998年后的通货紧缩中表现出来的明显弱效与此前在治理通货膨胀中的显著效果形成了鲜明对比,货币政策效力非对称性问题引起了国内政策和理论部门的关注。货币政策效力的非对称性主要是指货币政策效力在政策方向上的非对称性和在经济周期上的非对称性。基于经验检验结果,本文发现中国扩张性的货币政策对产出没有影响,紧缩性的货币政策能够有效影响产出,货币政策效力存在政策方向上的非对称性;紧缩性货币政策效力对时间因素非常敏感,只在短期内对产出具有显著的影响;经济周期因素对货币政策作用于实际产出的效果没有影响,货币政策效力不存在经济周期上的非对称性。     

Reducing health care costs: a case for quality

Today, it is not quality or access but cost that has become the primary motivator for change in the U.S. health care delivery system. Cost, as the driver, has created a frenzy of nationwide activity, searching, examining, and testing any and all ways that offer promise of financial health care stability. And cost, not quality or access, is the principal motivator for the ever accelerating national health care policy debate. But there is a relationship between costs and quality that has to be addressed if quality is to be maintained.     

Expert Views on Their Role as Policy Advisor: Pilot Study for the Cases of Electromagnetic Fields,Particulate Matter,and Antimicrobial Resistance

This perspective presents empirical data to demonstrate the existence of different expert views on scientific policy advice on complex environmental health issues. These views are partly research‐field specific. According to scientific literature, experts differ in the way they provide policy advice on complex issues such as electromagnetic fields (EMF), particulate matter (PM), and antimicrobial resistance (AMR). Where some experts feel their primary task is to carry out fundamental research, others actively engage in the policy dialogue. Although the literature provides ideas about expert roles, there exists little empirical underpinning. Our aim is to gather empirical evidence about expert roles. The results of an international study indicated that experts on EMF, PM, and AMR differ in the way they view their role in the policy dialogue. For example, experts differed in their views on the need for precaution and their motivation to initiate stakeholder cooperation. Besides, most experts thought that their views on the risks of EMF/PM/AMR did not differ from those of colleagues. Great dissensus was found in views on the best ways of managing risks and uncertainties. In conclusion, the theoretical ideal–typical roles from the literature can be identified to a certain extent.     

A Medicare reform primer

The use of the federal budget process to change Medicare policy is of importance to physician executives because of its impact on the health care delivery system. In particular, changes in Medicare policy, driven by the need to shore up the solvency of a politically popular program, will create changes for other public and private purchasers of health care. Reforming Medicare through the budget process is not new. Physician fees have been frozen, reduced, and selectively increased as a result. In 1983, the hospital reimbursement methodology was changed to prospective payment through this process. The budget process will continue to be used to make policy changes because of the large amount that Medicare occupies of the federal budget. Given the profound impact changes in Medicare can have in other health care sectors, the lack of consensus for a long-term solution would mean those in the health care arena will have to be prepared for significant annual policy changes through the reconciliation process.     

New, customized news

How can you get the news that you want, when you want it, no matter where you are? The idea of customized news is indeed new. Instead of sitting passively in front of the TV or turning the pages of your newspaper, you can program your computer to search for the news that is of interest to you from myriad sources. The idea of getting the news as you like it is all a product of the wonderful world of cyberspace. Browse the Web and find out if these news services are right for you.     

U.S. health care in conflict--Part I. The challenges of balancing cost,quality and access

Grappling with a technology explosion, an aging population and a growing number of uninsured, our health care system faces an uncertain and troubling future. Examine the critical issues influencing health care policy development and think about ways to address the dilemma of balancing cost, quality and access.     

The ethics of health care system reform

The United States is now engaged in a momentous national debate about health care. How can we provide the best care possible while simultaneously containing cost (to promote the general economic integrity of society) and somehow maintain a semblance of a free health care marketplace. This is not just a political question; it is also a question of ethics. It is an ethical consideration because the current debate is not just about designing or promoting health care systems that can best address our concerns for costs, quality, and accessibility. It appears that at least some participants in the debate would not stop at arguing their beliefs as valid; they would make their beliefs law. Some urge the creation of the right to health care as a matter of law. There are significant differences between beliefs and rights, however, and they need to be considered carefully in the ongoing debate over the future of this country's health care delivery and financing system.     

Defined contribution health care: future direction or fantasy?

Will payers embrace defined contribution plans as an alternative to traditional health insurance or is this new approach a pipe dream? Are consumers truly ready to make informed decisions on purchasing their own health care? This article explores barriers to defined contribution health plans, including consumer reluctance to take ownership of buying insurance and a preference for the cost predictability of liberal coverage in employer-sponsored programs versus MSAs or higher co-payment arrangements. For the ultimate form of defined contribution health care to work, several tax and insurance barriers must be overcome. As a practical matter, the author argues that the current employer-sponsored approach is the most efficient system for large employers.