1% Steps for Health Care Reform: Implications for health care policy and for researchers.

On the Critical List: The US Institution of Medicine

US health-care reform: victory, at last

Health Care on the Ballot: Election Has Profound Implications for the Future of Emergency Care

ImportanceThe United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains.ObjectivesTo estimate current levels of waste in the US health care system in 6 previously developed domains and to report estimates of potential savings for each domain.EvidenceA search of peer-reviewed and “gray” literature from January 2012 to May 2019 focused on the 6 waste domains previously identified by the Institute of Medicine and Berwick and Hackbarth: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. For each domain, available estimates of waste-related costs and data from interventions shown to reduce waste-related costs were recorded, converted to annual estimates in 2019 dollars for national populations when necessary, and combined into ranges or summed as appropriate.FindingsThe review yielded 71 estimates from 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature. Computations yielded the following estimated ranges of total annual cost of waste: failure of care delivery, $102.4 billion to $165.7 billion; failure of care coordination, $27.2 billion to $78.2 billion; overtreatment or low-value care, $75.7 billion to $101.2 billion; pricing failure, $230.7 billion to $240.5 billion; fraud and abuse, $58.5 billion to $83.9 billion; and administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: failure of care delivery, $44.4 billion to $93.3 billion; failure of care coordination, $29.6 billion to $38.2 billion; overtreatment or low-value care, $12.8 billion to $28.6 billion; pricing failure, $81.4 billion to $91.2 billion; and fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $282 billion.Conclusions and RelevanceIn this review based on 6 previously identified domains of health care waste, the estimated cost of waste in the US health care system ranged from $760 billion to $935 billion, accounting for approximately 25% of total health care spending, and the projected potential savings from interventions that reduce waste, excluding savings from administrative complexity, ranged from $191 billion to $282 billion, representing a potential 25% reduction in the total cost of waste. Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in US health care expenditures.

Many health systems continue to experiment with the best way to care for those patients who end up in the hospital most frequently.

Shifting care to alternative sites when clinically appropriate may be associated with reduced US health care spending, improved access, and, in some cases, improved care outcomes. To fill 2 main gaps in the current literature on site-of-care shifts: (1) understanding the clinician perspective on appropriateness of alternative care sites, given the central role they play in referrals and patient trust and (2) considering all potential sites where care could shift and calculating net savings potential. In this survey study, physicians (MDs and DOs), nurse practitioners, physician assistants, nurse anesthetists, radiology and imaging technicians, and psychologists were surveyed from September 17 to November 22, 2021, about potential shifts of care from the hospital setting to alternative sites. Participants were selected by the survey firm Intellisurvey to provide broad representation across all specialties of interest. A minimum of 34 clinicians responded to each question. Data were analyzed from April 2022 through October 2023. More than 5000 individual diagnostic and procedural codes were reviewed and sorted into 312 distinct care activities by an expert panel of physicians. Survey respondents were then provided with the 2019 claims-based distribution across sites of care for each care activity and were asked, "based on your clinical judgment, what portion of [care activity] could safely occur in each of the following sites of care, without compromising clinical outcomes?" Based on clinician-reported distributions, the total potential shift of volume from hospital-based settings to alternative sites and the associated net savings were estimated. Survey respondents included 1069 practicing clinicians (386 female [36.1%]; mean [SD] years since residency of physicians, 21.0 [9.7] years; mean [SD] age of nonphysicians, 45.3 [9.4] years) across specialties, all of whom practiced more than 20 clinical hours per week. There were 794 physicians (74.3%), and the remaining 275 respondents were midlevel professionals, such as physician assistants. Among 312 care activities surveyed, respondents indicated that 10.3 percentage points (95% CI, 10.0-10.5 percentage points) of commercial and 10.9 percentage points (95% CI, 10.7-11.1 percentage points) of Medicare volume currently taking place in hospital-based settings could shift to alternative sites with today's technology without compromising clinical outcomes. Across the entire US health care system, these shifts could be associated with a reduction in overall health care consumption spending ($3 562 339 000 000 000) by approximately $113.8 billion ($113 767 446 087 174 [3.2%]) to $147.7 billion ($147 661 672 284 263 [4.1%]) annually. In this study, a substantial net savings opportunity was estimated. However, realizing this potential will require ongoing alignment among organizations, clinicians, and policymakers to overcome barriers to these shifts.

The US health care system has reached a tipping point when there is both little doubt about the kind of change that is needed and much uncertainty about how to achieve it. This issue of JAMA, a theme issue on Critical Issues in US Health Care, includes 3 scholarly Special Communications and 11 authoritative and thought-provoking Viewpoints that map out this dilemma and highlight potential solutions. The topics all relate to fundamental aspects of how the US health care system functions, with subjects selected in an iterative process involving the editorial board of JAMA. The goal was to expand the discussion beyond just cost, quality, and value. In the first of 3 SpecialCommunicationarticles,Moses and colleagues1 present a comprehensive, detailed, and extensively referenced report that documents the anatomy of the US health system. Health care expenditures exceed $2.7 trillion annually, doubling since 1980 as a percentage of the nation’s gross domestic product. This article details how the United States spends that money each year and provides information on topics ranging from the number of health care personnel to the cost of information technology. Price increases (rather than greater provision of services) are driving increased costs, even as US health outcomes have fallen behind those of other countries. The rising tide of chronic illness is posing an unprecedented challenge. There has been substantial consolidation in many industries; for example, the airline, telecommunications, and automotive sectors of the economy have coalesced into relatively few major business entities. Cutler and Scott Morton2 describe the samephenomenon inhealthcare,particularly the hospital industry. Since themid-1980s, hospitalmarkets have shifted on average from including 5 independent major hospitals to 3. These changes beganbefore implementationof the Affordable Care Act (ACA) butwill hasten as the ACA rewards the integrated care that large networks may best provide. Measurement of quality has reached an almost frenzied state.Consumergroups, insurers,payers, licensingbodies, and various national groups all require different types of measures at the physician, patient, and hospital level. Panzer and colleagues3 highlight the demands and confusion inherent in scoresof competingqualitymeasures,whichcandistract from the essential task of making care better. There is no shortage of prescriptions for improving the delivery of care, and several Viewpoints in this issue of JAMA present potential solutions for core challenges. Cortese4 provides his vision for patient-focused, coordinated care, supported by innovative technology and rewarded by financial incentives. Although this approach should serve to improve quality, there are no data yet available to know whether the mHealth movement will indeed lead to better health outcomes. In contrast, while they are awash with data, it is not certain that the new technologies will reduce or increase the workload on physicians. Lynn5 calls for a shift in the focus on end-of-life care from diseases to people and for a redesign in long-term care to respect the dignity and desires of elderly individuals. Virtually everyone, including physicians, has a painful story to tell about end-of-life care in his or her family and the struggles with how to ensure “dying with dignity” in the United States. Cooper6 confronts an issue that has been problematic for the US health care system for decades: how many physicians are needed and what is the appropriate primary care/ specialist distribution. He calls for a greater number of physicians to meet the needs of an aging and increasingly diverse society, but with a restriction on federal support for residency, resources to train these additional physicians will be difficult to find. Few would deny the promise of these approaches. Yet model programs in these areas remain the exception rather than the rule. The time may have arrived to shorten the training period from medical school to residency to fellowship. At the national level, progress in advancing health care is slowandhalting.TheCenters forMedicare&MedicaidServices is promoting accountable care andother innovations through theMedicareandMedicaidprograms.However,broadchanges arenot on thehorizon, andCongress is distractedby efforts to undo the ACA. Ironically, addressing the increasing costs of healthcarewouldreducethepressureonthefederalbudgetand make political conflicts inWashington easier to resolve. What are some reasons for the paralysis? Berwick7 relates his firsthandexperienceswith the toxic politics of health care, passionately describes the fierceness of individuals andorganizations with entrenched financial interests, and calls for health professionals to join together to overcome these obstacles. Levey8 suggests that there is broad public misunderstanding about the country’s health care challenges, with the media bearing some of the responsibility. Several Viewpoints in this issue of JAMA propose creative solutions to resolving the many dilemmas faced by the US health care system, each requiring leadership and resolve and challenging the status quo. Emanuel9 calls for a “man on themoon”–typeaudaciousnational goalof limitinghealthcare expendituregrowth to thegrowthof thenational economy.He proposes an ambitious fiscal target, such that by 2020, per capita health care costs will increase no more than the gross Opinion

Innovation in Health Care: Time for a Gut Check

Shifting From Volume to Value: Opportunities and Challenges for the Field of Orthopaedic Surgery.

Balance Billing: How Did We Get Here and Where Are We Headed?: Hospitals and Insurers Can't Agree on Fair Prices—and Patients Have Suffered the Consequences. Now Congress is Stepping In

Health Care Reform and the Public Option

Do We Get What We Pay For? Transitioning Physician Payments Towards Value and Efficiency

The third and final part in this series will appear in next week 's issue. Part I appeared last week Last week we examined access to health care in the United States and how it has changed in recent years. This paper looks at the costs of American health care and the impact of important cost containment strategies. Health care spending has risen faster in the United States than in any other member nation of the Organisation for Economic Cooperation and Develop? ment (see figure). During 1970 to 1990 the rise was almost 12% a year.1 In 1990 the United States spent a staggering $666-2 billion or 12-4% of its gross domestic product on health care?$2566 per head of popula? tion.2 Concern is mounting because costs are digging deeper into the pockets of those who foot the health care bill?mainly businesses, the government, and the public?all of which have been hard hit by the recession and current slow economic growth. Meanwhile almost 36 million people have no health insurance at all,3 many going without even basic care. Most agree that any reform of health care in the United States must include serious cost containment measures if the paradox of excess and deprivation4 is to be addressed. This article examines why the costs of health care have risen, their effects, and the efforts to contain costs in relation to four groups of Americans?those with no health insurance, those with government funded health insurance through Medicare (the health pro? gramme for the elderly) and through Medicaid (the health programme for the poor), and those with private health insurance.

RAND Study Highlights Evolving Value of Emergency Medicine: Emergency Physicians Play Key Role as Gatekeepers to Hospital

Improving the Quality and Lowering the Cost of Health Care: Medicare Reforms from the National Commission on Physician Payment Reform