Cottage Industry to Postindustrial Care — The Revolution in Health Care Delivery

The authors of this article maintain that the current health care system is essentially a "cottage industry of non-integrated, dedicated artisans who eschew standardization. Services are often highly variable, performance is largely unmeasured, care is customized to individual patients, and standardized processes are regarded skeptically." They contend that quality improvement tools, such as standardization of value-generating processes, performance measurement, and transparent reporting of quality are essential to modernizing care delivery and that combining the three is the key to he transformation from cottage industry to postindustrial care. They state that physicians should welcome guidelines covering the basics of evidence-based care -- and in be better able to focus on the complex issues that require their training and expertise. Finally, the authors conclude, "Today’s good doctors should see process improvement as part of their core work."

Does the Congressional Budget Office Underestimate Savings from Reform? A Review of the Historical Record

According to this study by the Commonwealth Fund, the Congressional Budget Office (CBO) has historically underestimated savings and overestimated costs associated with health reforms.  The problem, according to the study, lies with the agency's "cautious methods."  Jon Gabel, a senior researcher at the National Opinion Research Center in Washington, D.C., argues that CBO's reliance on historical precedent in estimating the costs of substantial legislative reforms—such as those involving a dramatic shift in financial incentives for health care providers—often leaves it with little basis for estimating savings. "Too often, a lack of information is taken to mean zero savings, but zero is not a logical estimate," Gabel says.

The study examined three major changes made to health care financing in recent decades to see how CBO scored the expected changes in spending and what the actual outcomes of the new policies were. The reforms included: the change made in 1983 to the way Medicare pays hospitals under the prospective payment system and diagnosis-related groups; changes in the payment of hospitals, skilled nursing facilities, and home health care under the Balanced Budget Act of 1997; and the Medicare Modernization Act of 2003, which, among other things, made prescription drug coverage available to Medicare beneficiaries. In each case, CBO substantially underestimated savings and thereby overestimated the cost of Medicare to the federal budget. For example, actual federal spending on Medicare Part D drug benefits has been 40 percent lower than CBO's projection.

CBO has had particular difficulty assessing the impact of multiple, simultaneous changes designed to produce a synergistic effect—such as the comprehensive package of health care delivery, payment, and financing reforms now making its way through Congress, the study finds. Gabel says that increased fraud and abuse oversight should further control health spending.

Patient-Centered Medical Homes in Ontario

As the U.S. debates health care reform, the concept of “patient-centered medical homes” is receiving increasing attention. Many experts believe that medical homes with multidisciplinary teams and financial incentives for providing comprehensive care will lead to improvements in health, increase efficiency, and reduce costs of care while making practice more attractive for primary care physicians. This article describes lessons learned regarding the implementation of medical homes and their ability to accomplish these goals within Ontario’s experience with Family HealthTeams (FHTs). Within their implementation they have found, for example, that the use of interdisciplinary teams expands the range of services provided and reduces overload for individual physicians. Since physician income in Ontario is not based primarily on physician visits, practices can explore broader roles for team members and may use telephone, email, and group visits to enhance efficiency. The total number of visits per patient has not declined, but more visits appear to be occurring with team members other than the primary physician. Ontario continues to convert fee-for-service practices to patient-centered medical homes, so far with positive results. As Ontario and the U.S. have both faced similar problems with a decreasing supply of primary care providers, the authors conclude that the Ontario experience can provide useful lessons for the U.S. as it addresses its primary care crisis.

As Technology Surges, Radiation Safeguards Lag

This article is part of a series of articles that examine issues arising from the increasing use of medical radiation and the new technologies that deliver it. The article highlights the fact that while there are many benefits that new radiological equipment can bring to diagnosing and fighting diseases, the updated technology (such as I.M.R.T) also can lead to catastrophic results if it goes unmonitored. The article concludes that much of the problem stems from unregulated markets, and outdated saftey protocols.

The Budget and Economic Outlook: Fiscal Years 2010 to 2020

The Congressional Budget Office (CBO) cites federal healthcare spending as "the single greatest threat" to the United States' budget stability in its new report, The Budget and Economic Outlook: Fiscal Years 2010 to 2020. Under current law, Medicare spending will reach $1,038 billion in 2020, with Medicaid spending coming in at $458 billion. In 2009, higher unemployment drove up Medicaid spending by 9 percent ($18 billion). For the previous 10 years, the program's average annual growth rate had held at 7 percent. Medicare outlays also rose faster than average, jumping by 10 percent ($39 billion).

According to the report, Medicare and Medicaid spending will continue to grow at a combined average rate of about 7 percent a year between 2011 and 2020. Health spending is being affected by higher numbers of Medicare and Medicaid beneficiaries, as well as an increase in per-beneficiary spending that outpaces growth in the per-capital gross domestic product. Combined spending for Medicare and Medicaid currently equal about 5.5 percent of GDP. According to the CBO, "Under current law, spending for those two programs is expected to keep growing faster than the economy, reaching 6.6 percent of GDP by 2020 and potentially reaching 10 percent by 2035."