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Defined-contribution programs are becoming increasingly prevalent in employer-sponsored health insurance and may ultimately bring about substantial changes in U.S. health care. This shift will have both short- and long-term consequences for providers.

A judge has blocked a settlement that would have allowed Boston's Partners HealthCare to acquire three more health care providers. But policies should not only stop dominant hospital systems from acquiring more power but also encourage innovative entrants.

Current public and private healthcare information technology initiatives have failed to achieve secure integration among providers. Applying the "keep it simple, stupid" principle offers key guidance for solving this problem.

The most popular parts of the Affordable Care Act (ACA) are the most expensive. Universal coverage is a top priority not only for Democrats but also for President Trump. Both Republicans and Democrats want to preserve many costly coverage features of the ACA, including those that prevent insurers from precluding people with preexisting conditions and those that eliminate lifetime or annual coverage limits. The challenge is how to preserve these features and make insurance affordable.

Winter issues of The American Heart Hospital Journal traditionally focus on health care policy issues. As health care reform in the United States is a topic of major importance in the upcoming presidential election, we invited Dr Regina E. Herzlinger, the Nancy R. McPherson Professor of Business Administration at Harvard University and a noted expert in the field, to provide an analysis of the major proposals currently under debate by the candidates. We invite your comments in the coming months as the field of candidates narrows and the focus on reform sharpens.-Sylvan Lee Weinberg, Editor in Chief.

To enable improved cost control, quality, and access, US health care delivery is moving from fragmented fee-for-service delivery into various innovative integrated models, including accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and bundles, defined as a coordinated group of services for a specific need, administered over a predefined period. These innovations hold promise for patients whose complex care requirements account for the bulk of health care costs and who would reap the most benefit from a coalesced network of care.

Switzerland's consumer-driven health care system achieves universal insurance and high quality of care at significantly lower costs than the employer-based US system and without the constrained resources that can characterize government-controlled systems. Unlike other systems in which the choice and most of the funding for health insurance is provided by third parties, such as employers and governments, in the Swiss system, individuals are required to purchase their own health insurance. The positive results achieved by the Swiss system may be attributed to its consumer control, price transparency of the insurance plans, risk adjustment of insurers, and solidarity. However, the constraints the Swiss system places on hospitals and physicians and the paucity of provider quality information may unduly limit its impact. The Swiss health care system holds important lessons, including evidence about its feasibility and equity, for the United States, which is now embarking on its own consumer-driven health care system.

The revival of the economy in the US holds 2 powerful lessons for its healthcare system: know your customers and focus on their needs. Widespread inefficiency and inconvenience characterise the current healthcare system because it has failed to heed these lessons so far. Making the necessary changes will require substantial modifications by both government and healthcare providers. But, in the end, the result will reshape the future of healthcare.

T.R. Reid’s The healing of America is an engaging but thin epistle for universal health insurance coverage in the US. It is engaging because Reid, a long-time correspondent for the Washington Post, knows how to tell a good story. His book details his international quest for relief for his stiff shoulder. The cures he encounters range from a Tibetan-style urine tasting and Ayurvedic therapy in India, to the “wait and see” attitude of the Brits, to the surgical zeal of the US, the arch villain of the piece. His vignettes of some of the important, colorful figures who shaped national health care systems, such as Germany’s Iron Chancellor Otto von Bismarck, also add zest. But where Reid succeeds in the journalist’s metier — stories about personal encounters and people — he overreaches when he attempts to weave these episodes into a compelling comparison of the value for money of different health care systems. Reid’s data about the quality of health care consist mostly of his personal encounters, but can Reid, a well-seasoned journalist, be so naive as to believe that the medical care he receives as the employee of a world-famous newspaper is similar to that of the average Joe, Abir, or Heinz? Perhaps for this reason, Reid ignores the brutal inequity of the government-controlled health-care systems he so admires: rich, well-connected, and articulate people have much better access to health care. As the British and Canadian governments have long openly bemoaned, universal coverage does not mean equal access. Reid also ignores the fact that more than 10% of the population in single-payer countries such as the UK and Spain spurn single-payer coverage, opting instead to buy private health insurance that enables them to use private sector medical care providers. The statistics Reid offers are thin gruel. They do not consist primarily of raw data — the stuff of genuine scientific analysis — but rather of other people’s opinions of what constitutes excellence. Because a primary component of these quality ratings is whether a country has universal health care, the US cannot rate well. The conclusions he draws from his few data are dubious. For example, Reid asserts that infant mortality, a statistic for which the US rates poorly, is caused primarily by the absence of universal coverage. But surely the following additional explanations, neither of them considered, have some explanatory value: US cultural attitudes translate into more high-risk pregnancies coming to term (compared to other countries in which they would likely be terminated before birth) and these statistics are likely considerably affected by the diverse US population. The cited data are also notable for what they do not contain. Absent are statistics for areas in which US health care excels, such as risk-adjusted age at death from cancer, results achieved in part because of the willingness to spend more on expensive cancer drugs and other therapies. Rather, Reid dismisses problems that occur in single-payer countries because of stringent funding — impossibly long waiting lists, doctor strikes (and, unmentioned by him, doctor fraud), and the death of thousands due to a shortage of resources during a heat wave in France — as inevitable but not very consequential artifacts of not spending as much as the US. I grew particularly wary of Reid’s data as I read his account of US private health insurers (page 37). Reid erroneously avers that they use the term “medical loss” to describe their medical care expenses. But, after I made this observation more than a decade ago, US insurers stopped using this term. More alarming was Reid’s statement that most insurers spend 20% of their revenues on administrative expenses. Although Reid cites US Securities and Exchange Commission (SEC) filings in the text, his reference to this (largely incorrect) statement does not cite the SEC but rather a Wall Street Journal story about one insurer and a 2005 industry insider newsletter. The SEC filings of the insurer cited in the Wall Street Journal story contain a different administrative expense from that cited (I could not verify his other source because there is no public access to that newsletter). Last, Reid displays either a healthy dose of financial naivete or knee jerk anti-business attitudes when he singles out nonprofit insurers as the sine qua nons of the ideal system of universal coverage. In his view, nonprofits have no incentive to use their money for other than their clients. This view ignores many nonprofit scandals, such as nonprofit US hospitals that earn millions in profits while neglecting the uninsured. Consumers are protected only when they are fully informed and government vigorously prosecutes fraud and abuse, not by preferring one organizational form to others. If you are wondering, I too have long supported universal coverage and am no fan of noncompetitive private health insurers. But, sadly, this thin book did nothing to reinforce the validity of these views.

Switzerland’s consumer-driven health care system achieves universal insurance and high quality of care at significantly lower costs than the employerbased US system and without the constrained resources that can characterize government-controlled systems. Unlike other systems in which the choice and most of the funding for health insurance is provided by third parties, such as employers and governments, in the Swiss system, individuals are required to purchase their own health insurance. The positive results achieved by the Swiss system may be attributed to its consumer control, price transparency of the insurance plans, risk adjustment of insurers, and solidarity. However, the constraints the Swiss system places on hospitals and physicians and the paucity of provider quality information may unduly limit its impact. The Swiss health care system holds important lessons, including evidence about its feasibility and equity, for the United States, which is now embarking on its own consumer-driven health care system.

With the technical assistance of Elisabeth A. Hall, A.B. A management control system was adapted from its applications in the business world to a neighborhood health center. The system was planned, then implemented in the health center, and management control data were collected and used for a study period of 1 year. The system proved acceptable to the professionals in the health center and was associated with motivational changes in the health center staff and subsequent modifications of the production characteristics of the health center. Such a system, even with the limitations resulting from a first effort, seems adaptable to the medical care setting and may be useful in modifying some of the inefficiencies that exist within the health system.