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Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort—a new Charter for Primary Care—is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations. [ABSTRACT FROM AUTHOR]

Many policymakers believe that comparative effectiveness research will reduce "waste" in the U.S. health care system by providing guidance on what health care options work best for different patients. How such research will produce findings that identify waste has not been clearly elucidated. This paper presents a conceptual framework for different evidentiary categories of what we call "marginal medicine." This framework could help clinicians, researchers, and policymakers align the results of comparative effectiveness research with efforts to identify opportunities to improve the value of health care services. [ABSTRACT FROM AUTHOR]

Rapidly rising spending has prompted debate about increasing cost sharing in Medicaid and the Children's Health Insurance Program (CHIP). In this paper we assess the role of cost sharing in Medicaid and the CHIP and its potential financial burden on low-income families with children. We find that many families would face high health spending burdens even with minimal cost sharing for their publicly insured children. Adding even modest cost sharing for such children could greatly increase high financial burdens. Our results also suggest that implementing income-based caps on family spending can help ad- dress the burden of high spending for low-income families. [ABSTRACT FROM AUTHOR]

One key issue in health reform concerns the relative roles of coverage offered through private insurance and public programs. This paper compares the experiences of aged Medicare beneficiaries with those of people under age sixty-five who have private employer coverage. Compared with the employer-coverage group, people in the Medicare group report fewer problems obtaining medical care, less financial hardship due to medical bills, and higher overall satisfaction with their coverage. Although access and bill payment problems increased across the board from 2001 to 2007, the gap between Medicare and private employer coverage widened. [ABSTRACT FROM AUTHOR]

Numerous studies in the United States have examined the association between quality and spending at the regional level. In this paper we evaluate this relationship at the level of individual hospitals, which are a more natural unit of analysis for reporting on and improving accountability. For all of the quality indicators studied, the association with spending is either nil or negative. The absence of positive correlations suggests that some institutions achieve exemplary performance on quality measures in settings that feature lower intensity of care. This finding highlights the need for reporting information on both quality and spending. [ABSTRACT FROM AUTHOR]

This paper presents key insights from California's recent experience in developing a plan for universal health coverage with "shared responsibility" among individuals, employers, and governments. A major challenge was finding an acceptable balance among the goals of affordability, equity, and cost to the state. Although reform did not pass, the state's approach-particularly differences from Massachusetts regarding modest-income workers and related employer and public roles-provides important insights for federal reform. [ABSTRACT FROM AUTHOR]

The boycott of potio vaccination in three Northern Nigerian states in 2003 created a global health crisis that was political in origin. This paper traces the diplomatic actions that were taken by the Global Polio Eradication Initiative, the United Nations, and the U.S. government, to restart polio vaccination and resolve the crisis. The polio vaccination boycott in Northern Nigeria provides a useful case study of the practice of global health diplomacy. [ABSTRACT FROM AUTHOR]

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort-a new Charter for Primary Care-is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations. [ABSTRACT FROM AUTHOR]

In the United States, the complex process of getting health care technologies into practice takes place in a competitive health system that is driven by technological innovation. Federal, state, and local governments' roles in the diffusion process are limited. In low-income countries, where competitive markets are not as prominent, diffusing medical innovations requires an alternative understanding of how new technologies are adopted. This paper describes how, in low-income countries, the lack of functioning markets serves as a barrier to the transfer of necessary health technologies, and why governments must act as stewards in promoting technologies there. [ABSTRACT FROM AUTHOR]

State hospitals were once the most prominent components of U.S. public mental health systems. But a major focus of mental health policy over the past fifty years has been to close these facilities. These efforts led to a 95 percent reduction in the country's state hospital population. However, more than 200 state hospitals remain open, serving a declining but challenging patient population. Using national and state-level data, this paper discusses the contemporary public mental hospital, the forces shaping its use, the challenges it faces, and its possible future role in the larger mental health system. [ABSTRACT FROM AUTHOR]

This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators. [ABSTRACT FROM AUTHOR]

As the largest payer for health services in the United States, Medicare has the potential to use its payment policies to stimulate change in the organization of care to improve quality and mitigate cost growth. This paper proposes a framework in which Medicare would offer an array of new bundled payment options for physician group practices, hospitals, and delivery systems, with incentives to encourage greater integration in the organization of health care delivery and the provision of more coordinated care to beneficiaries. These changes could also serve as a model for other payers to improve quality and efficiency throughout the health system. [ABSTRACT FROM AUTHOR]

This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators. [ABSTRACT FROM AUTHOR]

As the largest payer for health services in the United States, Medicare has the potential to use its payment policies to stimulate change in the organization of care to improve quality and mitigate cost growth. This paper proposes a framework in which Medicare would offer an array of new bundled payment options for physician group practices, hospitals, and delivery systems, with incentives to encourage greater integration in the organization of health care delivery and the provision of more coordinated care to beneficiaries. These changes could also serve as a model for other payers to improve quality and efficiency throughout the health system. [ABSTRACT FROM AUTHOR]

Health care reform has reemerged as a policy imperative. Congressional discussions regarding sizable federal investments in health information technology (IT) infrastructure have revitalized the vision of health IT as a critical component of accelerating improvements in the quality and value of health care for all Americans. Policymakers will be challenged to link investments in the health information infrastructure to the objectives of health care reform. The purpose of this paper is to articulate some near- and long-term steps that increase the likelihood of achieving high-value health care with the aid of health IT. [ABSTRACT FROM AUTHOR]

Health information technology (IT) has great potential to transform health care and inform population health goals in clinical research, quality measurement, and public safety. To fully realize the benefits of health IT for population health, we must focus on new models that maximize efficiency, encourage rapid learning, and protect patients' privacy. In this paper we explore the advantages of a networked model for analyzing population health information, providing several examples. Although broadening the use of networked models is challenging, the societal benefits of a networked model merit continued exploration and the development of workable solutions. [ABSTRACT FROM AUTHOR]

Innovation in health care requires new ideas and the capital to develop and commercialize those ideas into products or services. The necessary capital is often "venture capital," but the link between public policy and the venture capital industry has not been well examined. In this paper we explore the link between venture capital and innovation in health care, and we present new descriptive data from a survey of health care venture capital fund managers. Respondents generally viewed policy levers (for example, reimbursement and regulations) as important risks to venture capital investments, potentially affecting their ability to raise capital for early-stage investment funds. [ABSTRACT FROM AUTHOR]

This paper reviews recent trends in Medicare Advantage, examining program costs, access to plans, enrollment, plan bids, and benchmarks. We find that current policy has favored the growth of particular types of plans. Bid data show that plans are paid, on average, 113 percent of what expenditures would have been under the traditional Medicare program. Although some of the plan payments are used to finance extra benefits for enrollees, paying plans at higher than fee-for-service levels could affect the sustainability of the Medicare program and result in increased costs for all taxpayers and beneficiaries. [ABSTRACT FROM AUTHOR]

Unhealthy behavior is a major cause of poor health outcomes and high health care costs. In this paper we describe an agenda for research to guide broader use of patient-targeted financial incentives, either in conjunction with provider-targeted financial incentives (pay-for-performance, or P4P) or in clinical contexts where provider-targeted approaches are unlikely to be effective. We discuss evidence of proven effectiveness and limitations of the existing evidence, reasons for underuse of these approaches, and options for achieving wider use. Patient-targeted incentives have great potential, and systematic testing will help determine how they can best be used to improve population health. [ABSTRACT FROM AUTHOR]

This paper proposes a national initiative for Medicare patients with cancer. It would include (1) a rapid-learning system for comparative effectiveness; (2) a quality measurement system; and (3) payment reforms to reward high-quality care. In implementing this strategy, the U.S. Department of Health and Human Services (HHS) would make extensive use of new computerized databases for clinical research and quality measurement. Legislation will be needed for full national implementation. Similar initiatives could be started for other priority areas in Medicare. Medicare could become a national leader in advancing high-quality, effective care. [ABSTRACT FROM AUTHOR]

Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCM's effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes. [ABSTRACT FROM AUTHOR]

This paper argues that a desirable health reform plan should accept some features that the Obama and McCain plans have in common, and combine other features from each of the plans. Useful combinations include the presence of both public and private options and a system of credits that are more generous for lower-income households (Obama) and creation of a system of public subsidies that is incentive-neutral across individual and group insurance, curtailment of the current tax subsidy to high levels of coverage for high-income households, and the use of targeted high-risk pools and guaranteed renewability rather than community rating (McCain). [ABSTRACT FROM AUTHOR]

This paper analyzes the politics of paying for health care reform. It surveys the political strengths and weaknesses of major options to fund universal coverage and explores obstacles to changing how the United States finances health care. Finding a politically viable means to finance universal coverage remains a central barrier to enacting health reform. [ABSTRACT FROM AUTHOR]

The threat of mass-casualty disasters raises concern about the adequacy of hospitals' surge capacity. This paper measures surge capacity as the number of empty staffed beds per capita at the county level and compares it to a disaster-planning benchmark released by the federal government. The percentage of the U.S. population living in counties falling below the benchmark increased from 19 percent in 2000 to 30 percent in 2005. Limitations in surge capacity are associated with rapid population growth but not with higher rates of hospital use. Limitations appear to be most severe along the East Coast and in the West. [ABSTRACT FROM AUTHOR]

Anecdotal evidence suggests that innovative medical devices often arise from physicians' inventive activity, but no studies have documented the extent of such physician-engaged innovation. This paper uses patent data and the American Medical Association Physician Masterfile to provide evidence that physicians contribute to medical device innovation, accounting for almost 20 percent of approximately 26,000 medical device patents filed in the United States during 1990-1996. Moreover, two measures indicate that physician patents had more influence on subsequent inventive activity than nonphysician patents. This finding supports the maintenance of an open environment for physician-industry collaboration in the medical device discovery process. [ABSTRACT FROM AUTHOR]

This paper describes the rapid growth of imaging services in Medicare and recent changes in how Medicare pays for these services. Certain imaging services may still be overvalued because the Centers for Medicare and Medicaid Services (CMS) uses assumptions for calculating imaging equipment costs that may be inaccurate and uses newer practice- cost data for some, but not all, specialties. In addition, the CMS's method of adjusting for geographic differences in input prices may overpay for imaging services in high-cost areas and underpay in low-cost areas. We explore issues related to improving the accuracy of imaging payments. [ABSTRACT FROM AUTHOR]

This paper describes how intensifying competitive pressures in the health system are simultaneously driving increased demand for safety-net care and taxing safety-net providers' ability to maintain the mission of serving all, regardless of ability to pay. Although safety-net providers adapted to previous challenges arising from managed care, health system pressures have been more intense and more generalized across different sectors in recent years than in the past. Providers are adopting some of the same strategies being used in the private sector to attract higher-paying patients and changing their "image" as a safety-net provider. [ABSTRACT FROM AUTHOR]

From 2004 to 2007 the California HealthCare Foundation's Step by Step: Local Coverage Expansion initiative supported insurance coverage expansions for uninsured children and adults in thirty California counties. In this paper we describe the initiative and its achievements as well as challenges for grantees. Also, we discuss the implications of the initiative's outcomes for expanding coverage locally and more broadly. Implementing new insurance programs is possible in the most difficult settings. Although there are real challenges to sustaining these expansions and limits to what they can accomplish in the face of major unmet needs, they may lay useful groundwork for broader expansions later. [ABSTRACT FROM AUTHOR]

In this paper we explore whether increasing individuals' activation (self-management) levels could hold potential for reducing racial and ethnic disparities in health. A causal model is posited that assumes that social-environmental factors influence activation levels, which in turn influence health outcomes. Relationships are examined separately for whites and African Americans, and findings are supportive of the model for both groups. Simulations of what would happen to outcomes if there were racial parity in activation predict a narrowing of the racial gap in health and behavior. The findings suggest that a focus on increasing activation holds potential for addressing racial and ethnic disparities in health. [ABSTRACT FROM AUTHOR]

This paper assesses the evolving "facilitated consumerism" model of health care at the community level using data from the Community Tracking Study (CTS). We find that in a relatively short time, large employers and health plans have made notable progress in putting the building blocks in place to support their vision of consumerism. However, developments in the CTS communities suggest that the consumerism strategy evolving in local markets is more nuanced than implied by some descriptions of health care consumerism. [ABSTRACT FROM AUTHOR]

To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health System's innovation strategy for care model redesign. Geisinger's clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisinger's characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform. [ABSTRACT FROM AUTHOR]

This paper examines variations in health spending by children, working-age adults, and seniors for selected years between 1987 and 2004. Seniors spent far more per person than children or working-age adults, but the relative gap between the age groups has not changed much since 1987 except for those age eighty-five and older. Since the inception of the State Children's Health Insurance Program (SCHIP) in 1997, the proportion of children's health spending financed by public sources has increased, while the share paid for out of pocket has decreased. The future age-mix is expected to have a major impact on nursing home spending growth while minimally affecting overall Medicare spending growth. [ABSTRACT FROM AUTHOR]

In 2003 the Indiana Office of Medicaid Policy and Planning implemented the Indiana Chronic Disease Management Program (ICDMP). This paper reports on the fiscal impact of the ICDMP from the state's perspective, as estimated from the outcomes of a randomized trial. Medicaid members with congestive heart failure (CHF) or diabetes, or both, were randomly assigned by practice site to chronic disease management services or standard care. The effect of the ICDMP varied by disease group and risk class: while cost savings were achieved in the CHF subgroup, disease management targeted to patients with only diabetes resulted in no significant fiscal impact. [ABSTRACT FROM AUTHOR]

For the first time since the early 1990s, the political environment in the United States offers the real possibility of fundamental reform of our fraying health care system. Although the current moment appears promising for reform, the opportunity could easily dissipate as it has in the past. In this paper, we offer seven observations on the key opportunities and pitfalls for health care reform advocates in this pivotal election year, based on our analysis of the current political dynamic and recent public opinion research. [ABSTRACT FROM AUTHOR]

In this paper we compare health insurance coverage for U.S. citizen children in all-citizen and mixed families in the fifteen states with the largest share of children in mixed families. Insurance coverage is lower and state variation in coverage is higher for children in mixed families vis-à-vis children in all-citizen families. The main challenges for states are tackling uninsurance among all low-income children and addressing the very low rates of employer-sponsored insurance for all low-income children and for children in all mixed families, regardless of income. We discuss state policy options to address the needs of children in mixed families. [ABSTRACT FROM AUTHOR]

For twenty-three million Americans who speak English less than "very well," language barriers lead to lower quality of and worse access to health care. Although the breadth of existing federal and state language access laws might seem sufficient, the lack of comprehensive implementation and enforcement leaves millions of patients with limited English proficiency forced to accept a lower quality of care than English speakers receive. This paper reviews existing laws and offers solutions focusing on five themes: access, funding, education, quality improvement, and accountability. Improving language access is essential to ensure that the language one speaks does not affect one's health or mortality. [ABSTRACT FROM AUTHOR]

Dental care is the largest unmet health need among low-income children, yet it garners relatively little attention from policymakers and grantmakers. Foundation giving for dental education and dental care totaled $55.6 million in 2005-a mere 1.6 percent of total health grant making and 0.34 percent of total foundation giving. Health foundations have played a critical role in advancing the U.S. health care system. The need for investments from grantmakers to spur innovation and change in the dental care system is great. This paper describes a range of ideas for strategic grant making to improve oral health in the United States. [ABSTRACT FROM AUTHOR]

Access to care for racial and ethnic minority groups, low-income populations, and the un- and underinsured has been problematic despite expansion in the health workforce. Workforce policies that improve access to care are needed, as is funding to support them. Reviewing evidence related to providers' patterns of service to the underserved, this paper concludes that underrepresented minority health professionals have consistently been more likely than those from Low socioeconomic backgrounds or the National Health Service Corps to deliver health care to the underserved. These findings have implications for policies and programs that might leverage the workforce to better meet the needs of disadvantaged patients. [ABSTRACT FROM AUTHOR]

This paper compares pharmaceutical spending, availability, use, and prices in twelve countries in 2005. Drug spending per capita was higher in the United States than in other countries. The United States had relatively high use of new drugs and high-strength formulations; other countries used more of older drugs and weaker formulations. Thus, whether U.S. overall volume of use is lower or higher depends on the measure of volume and type of product. Comprehensive price indexes show foreign prices to be 20-40 percent lower than U.S. manufacturer prices, but only 10-30 percent lower than U.S. public prices. Generics are cheaper in the United States than in other countries. [ABSTRACT FROM AUTHOR]

This paper estimates the effects of a large employer's value-based insurance initiative designed to improve adherence to recommended treatment regimens. The intervention reduced copayments for five chronic medication classes in the context of a disease management (DM) program. Compared to a control employer that used the same DM program, adherence to medications in the value-based intervention increased for four of five medication classes, reducing nonadherence by 7-14 percent. The results demonstrate the potential for copayment reductions for highly valued services to increase medication adherence above the effects of existing DM programs. [ABSTRACT FROM AUTHOR]

The care of Americans with severe chronic illnesses is disorganized, unnecessarily costly, and undisciplined by sound clinical science. The federal government should in- vest in a crash program to improve the scientific basis of managing chronic illness, and the Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to ensure that within ten years all Americans with severe chronic illnesses have access to accountable health care organizations providing evidence-based prospective care. This paper recommends a strategy for achieving this goal. [ABSTRACT FROM AUTHOR]

The decision to undergo many discretionary medical treatments should be based on informed patient choice. Shared decision making is an effective strategy for achieving this goal. The Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to assure that all Americans have access to a certified shared decision-making process. This paper outlines a strategy to achieve informed patient choice as the standard of practice for preference-sensitive care. [ABSTRACT FROM AUTHOR]

More than two-thirds of uninsured U.S. children are eligible for public coverage, and most current policy debate assumes that this is largely attributable to poor takeup. This paper explores the contribution of poor retention in Medicaid and the State Children's Health Insurance Program (SCHIP) to this phenomenon. The results indicate that one-third of all uninsured children in 2006 had been enrolled in Medicaid or SCHIP the previous year. Among those uninsured but eligible for public coverage in 2006, at least 42 percent had been enrolled in Medicaid or SCHIP the previous year. Both of these measures of disenrollment have increased since 2000. [ABSTRACT FROM AUTHOR]

In this paper we argue that there is a real need for Medicaid reform primarily because of the large differences among states in coverage and benefits and because of the program's high and rising costs. We describe and develop several options for Medicaid reform that would expand coverage, provide fiscal relief to states, shift responsibility for some or all of the care of dual eligibles to the federal government, and eliminate or restructure disproportionate-share hospital (DSH) payments. We conclude with a discussion on a number of other issues, particularly Medicaid cost containment and the federal matching payment structure. [Health Affairs 26, no. 2 (2007): w254-w270 (published online 23 February 2007; 10.1377/hlthaff.26.2.w254)] [ABSTRACT FROM AUTHOR]

When everyone is required to pay the same out-of-pocket amount for health care services whose benefits depend on patient characteristics, there is enormous potential for both under- and overuse. Unlike most current health plan designs, Value-Based Insurance Design (VBID) explicitly acknowledges and responds to patient heterogeneity. It encourages the use of services when the clinical benefits exceed the cost and likewise discourages the use of services when the benefits do not justify the cost. This paper makes the case for VBID and outlines current VBID initiatives in the private sector as well as barriers to further adoption. [Health Affairs 26, no. 2 (2007): w195-w203 (published online 30 January 2007; 10.1377/hlthaff.26.2.w195)] [ABSTRACT FROM AUTHOR]

Many current policies and approaches to performance measurement and payment reform focus on individual providers; they risk reinforcing the fragmented care and lack of coordination experienced by patients with serious illness. In this paper we show that Medicare beneficiaries receive most of their care from relatively coherent local delivery systems comprising physicians and the hospitals where they work or admit their patients. Efforts to create accountable care organizations at this level-the extended hospital medical staff-deserve consideration as a potential means of improving the quality and lowering the cost of care. [Health Affairs 26, no. 1 (2007): w44-w57 (published online 5 December 2006; 10.1377/hlthaff.26. 1.w44)] [ABSTRACT FROM AUTHOR]

Findings from a Medicaid pay-for-performance (P4P) demonstration suggest that "money talks" only sometimes, when supportive program elements give it voice. In this paper we examine five Medicaid-focused health plans that implemented new financial incentives for physicians to improve the timeliness of well-baby care. By contrasting the experiences of plans with better and worse outcome trends, we identify key program features—including strong communication with providers and placing enough dollars at stake to compensate providers for the effort required to obtain them—taking into account the starting point. The findings also highlight barriers to improvement that future Medicaid P4P efforts should consider. [ABSTRACT FROM AUTHOR]

Using multiple databases, this paper examines recent trends in the affordability and comprehensiveness of small-group and individual health insurance markets in California. Both became less affordable over the study period. In 2006, a single person age 32-52 earning the median income who purchased individual insurance spent on average 16 percent of income on premiums and out-of-pocket medical expenses. For individual insurance, the share of medical expenses paid by insurance as opposed to patients declined from 2002 to 2006. In the small-group market, premiums rose more than 50 percent from 2003 to 2006, but the proportion of claims paid by insurers for a standardized population remained constant. [ABSTRACT FROM AUTHOR]

Non-Hispanic whites are significantly more likely to have health insurance coverage than most racial/ethnic minorities, and this differential grew during the 1990s. Similarly, wealthier Americans are more likely to have health insurance than the poor, and this difference also grew over the 1990s. This paper examines the role of provider competition in increasing these disparities in insurance coverage. Over the 1990s, the hospital industry consolidated; we analyze the impact of this consolidation on health insurance take-up for different racial/ethnic minorities and income groups. We found that the hospital consolidation wave increased health insurance disparities along racial and income dimensions. [ABSTRACT FROM AUTHOR]

Mounting malpractice liability costs might affect physician practice patterns in many ways, such as increasing the use of diagnostic procedures while reducing major surgeries. This paper quantifies the association between malpractice liability costs and the use of physician services in Medicare. We find that higher malpractice awards and premiums are associated with higher Medicare spending, especially for imaging services that are often believed to be driven by physicians' fears of malpractice. The 60 percent increase in malpractice premiums between 2000 and 2003 is associated with an increase in total Medicare spending of more than $15 billion. [ABSTRACT FROM AUTHOR]