Academic journal article Public Health Reviews; Rennes

United States Innovations in Healthcare Delivery

Academic journal article Public Health Reviews; Rennes

United States Innovations in Healthcare Delivery

Article excerpt

INTRODUCTION

Nearly all nations are working to improve their healthcare delivery systems. The growth of chronic illness and aging populations, in particular, has placed a substantial burden on healthcare systems in both developed and developing countries. For example, 60 percent of all deaths worldwide (25 million people) are due to chronic illness. Eighty percent of these occur in low and middle-income countries, and deaths due to chronic illness are double the number due to infectious diseases.1 Chronic illnesses also have a huge economic impact. For example, over the next ten years, chronic illness will result in $558 billion of costs as well as lost productivity in China; $237 billion in India; and $33 billion in the United Kingdom.2 In the US, nearly three-quarters of Americans over the age of 65 suffer from a chronic illness3 and half of them have more than one chronic illness. Chronic illness in the United States accounts for 75 percent of the $2.4 trillion of healthcare expeditures.4

At the same time, there is growing recognition that a country's health status is heavily influenced by underlying economic, physical, environmental, and social determinants. These involve multiple sectors outside of healthcare including agriculture, education, housing, and transportation among others. Savings that might accrue from having more cost-effective healthcare delivery systems to treat chronic illness could be redeployed in health promotion and related activities offering a greater return on investment in improving population health. As a result, there is growing interest in both the primary prevention of chronic illness and in better management of those with existing chronic illness.

The US has the most expensive healthcare system in the world (16 percent of GDP) with health status indicators that are, at best, only average in comparison with the less costly health systems of other countries. Thus, the pressure to provide more cost-effective care is particularly intense in the US, as it attempts to expand health insurance coverage and address serious cost and quality issues. Earlier efforts to expand the health maintenance organizations (HMOs) established in the 1970s to reduce costs backfired when both physicians and patients rebelled against the limited choices and prior authorization required for certain services and referrals to specialists. The result has been a relative decline in group practice HMOs and a relative increase in preferred provider organizations (PPOs) whose attempts to exercise cost containment and quality improvement initiatives are generally less systematic than those undertaken by HMOs. The result is that providers in the US remain largely fragmented, and the majority of physicians still practice in solo, small partnerships, and small group practices paid largely on a fee-for-service basis. Therefore, the system is poorly designed to treat chronic illness - the major health challenge of the 21st century.

To address the above challenge, the US in its current healthcare reform initiative is beginning to move away from the fee-for-service payment model to a capitation payment model based on a set dollar amount per enrolled subscriber either in total or per selected conditions; bundled payments comprising a single payment to both physicians and hospitals for specific procedures or conditions such as coronary artery bypass graft surgery and rewards or bonuses for achieving predetermined quality outcomes such as reducing preventable hospital readmissions. At the same time, the United States is experimenting with new organizational forms potentially able to respond to the new payment incentives. We discuss three such innovations - the Patient-Centered Medical Home (PCMH), the Accountable Care Organization (ACO) and the Population Health Management System (PHMS). These three are selected because of their potential for providing more cost effective disease prevention and management of patients with chronic illness. …

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