Health Care Reform Strategies Research Articles

The doctor vote: Interactions between political ideological preferences and healthcare reform strategies among U.S. physicians

IntroImproving the American healthcare system has consistently predominated the domestic policy agenda in the United States for decades. However, physicians have traditionally played a small role in the U.S. legislative process despite their direct observations of the obstacles that cost, access, and quality can have on their patients and their care. The goal of this study was to examine the relationship between physician political ideological preferences and health policy reform options. MethodsWe conducted a cross-sectional survey of 3,001 currently practicing U.S. physicians to predict how self-identification as liberal, moderate, or conservative impacted a physician’s policy preferences under the domains of cost, access, and quality. ResultsA total of 536 (18.8%) out of 3,001 physicians responded to the survey. Overall, 32% of physicians identified as liberal, 43% as moderate, and 22% as conservative. ConclusionLiberal-identifying physicians favored traditionally liberal reform ideas (a national health plan or public option), while conservative physicians preferred conservative policies (free market optimization). However, variation within political groups and domains of healthcare suggest that no single reform policy will be unanimously supported by every physician within a political group. Nonetheless, physicians are unanimously dissatisfied with the state of our current system, and physician-supported healthcare reform should be a national priority.

ГЕНЕЗИС РОЗВИТКУ ПРАВОВОГО РЕГУЛЮВАННЯ У СФЕРІ ОХОРОНИ ЗДОРОВ’Я В УКРАЇНІ ЗА ЧАСИ НЕЗАЛЕЖНОСТІ

The article analyzes the genesis of the development of legal regulation in the field of health care in Ukraine in times of independence. Four stages of normative and legal base creation of system of medical care of the population as the leading link of the state social policy are considered. The first stage in 1991–2000 was the most difficult, on one hand it was necessary to preserve the health care system, that was left over from the old government, and on another hand - to start reforming the normative and legal framework to further ensuring of a minimum level of social guarantees for population on health care provision. At the second stage in the period 2000–2010 of the development of the health care system in Ukraine the implementation of the Concept started, activities were carried out to identify the main directions and approbation of key mechanisms for reforming of the medical sector. During the third period in 2010-2013, a large-scale reform of the health care system in some regions was launched as part of a pilot project. The fourth stage began in 2014 and continues till today. In August 2014 the Ministry of Health initiated the development of a National Strategy for Health Care Reform in Ukraine. By means of the new strategic approaches in improving of the quality and availability of aid and reducing financial risks for people a new impetus to industry reform was required. It is emphasized that the third and fourth stages, from the standpoint of reforming the medical system, were the most productive. It is emphasized that the provisions of the National Strategy for Health Care Reform in Ukraine are currently being implemented. The document has two main objectives: first of all to stimulate the proper reforms, but at the same time to demonstrate to the decision-makers that health and health care are powerful tools in politics. The strategy clarifies the horizon for reform, provides it with structures and demonstrates the potential of various measures aimed at the effective development of health care services. Based on the strategy, the Ministry of Health has also developed a Concept for reforming the financing of the health care system and bills that will launch a reform of Ukrainian medicine. The strategy should be the basis for creating a detailed action plan for reforming of Healthcare with proposals for the short, medium and long term perspective.

Would universal general practitioner care impact Irish adolescents’ utilisation?

IntroductionHealth systems’ characteristics influence individuals’ health care utilisation. Unlike their European neighbours the majority of Irish citizens pay for General Practitioner (GP) care. The current strategy for health care reform proposes universal GP care (i.e. the removal of GP care fees), to be introduced on a phased basis, prioritising under 18s. MethodsEmploying data from the Growing Up in Ireland survey, and controlling for health care need, and other predisposing and enabling factors, propensity score matching is used to estimate the effect of GP cover (free GP care at point of use) on GP utilisation over a 12-month period amongst 16/17 year olds (n= 4308). ResultsResults indicate having GP cover increases the average number of GP consultations by 38% per annum. When the sample is restricted to individuals without chronic conditions, a 42% increase in annual number of GP consultations is found. It is reasonable to expect that extending free GP care via a universal care model would be associated with a higher propensity to utilise GP services amongst 16/17 year olds. ConclusionsThis has economic implications for health care budgets and workforce planning. While most adolescents are healthy, investment in their health provides current and future health benefits; however a universal system will require investment, necessitating displacement of resources elsewhere, to meet demand.

Australian podiatrists scheduled medicine prescribing practices and barriers and facilitators to endorsement: a cross-sectional survey

BackgroundNon-medical prescribing is one healthcare reform strategy that has the potential to create health system savings and offer equitable and timely access to scheduled medicines. Podiatrists are well positioned to create health system efficiencies through prescribing, however, only a small proportion of Australian podiatrists are endorsed to prescribe scheduled medicines. Since scheduled medicines prescribed by Australian podiatrists are not subsidised by the Government, there is a lack of data available on the prescribing practices of Australian podiatrists. The aim of this research was to investigate the prescribing practices among Australian podiatrists and to explore barriers and facilitators that influence participation in endorsement.MethodsParticipants in this quantitative, cross-sectional study were registered and practicing Australian podiatrists who were recruited through a combination of professional networks, social media, and personal contacts. Respondents were invited to complete a customised self-reported online survey, developed using previously published research, research team’s expertise, and was piloted with podiatrists. The survey contained three sections: demographic data including clinical experience, questions pertaining to prescribing practices, and barriers and facilitators of the endorsement pathway.ResultsRespondents (n = 225) were predominantly female, aged 25–45, working in the private sector. Approximately one quarter were endorsed (15%) or in training to become endorsed (11%). Of the 168 non-endorsed respondents, 66% reported that they would like to undertake training to become an endorsed prescriber.The most common indications reported for prescribing or recommending medications include nail surgery (71%), foot infections 474 (88%), post-operative pain (67%), and mycosis (95%). The most recommended Schedule 2 medications were ibuprofen, paracetamol, and topical terbinafine. The most prescribed Schedule 4 medicines among endorsed podiatrists included lignocaine (84%), cephalexin (68%), flucloxacillin (68%), and amoxicillin with clavulanic acid (61%).ConclusionPodiatrists predominantly prescribe scheduled medicines to assist pain, inflammatory, or infectious conditions. Only a small proportion of scheduled medicines available for prescription by podiatrists with endorsed status were reportedly prescribed. Many barriers exist in the current endorsement for podiatrists, particularly related to training processes, including mentor access and supervised practice opportunities. Suggestions to address these barriers require targeted enabling strategies.

НОРМАТИВНО-ПРАВОВЕ РЕГУЛЮВАННЯ У СФЕРІ НАДАННЯ МЕДИЧНИХ ПОСЛУГ НАСЕЛЕННЮ

The achievements and shortcomings of the first stage of providing medical services to the population are studied. The regulatory framework is analyzed. The consequences of the implementation of the National Strategy for Health Care Reform in Ukraine for 2014-2018 are considered. The main tasks of continuing to reform the domestic health care system are indicated. Measures to test the provision of secondary (specialized) and tertiary (highly specialized) medical care are disclosed. The author concludes that regulations of general and special nature provide medical services to the population. In essence, most legal acts meet European standards and are in line with European Union law. It has been established that the first positive results have been achieved so far: the provision of primary, secondary and tertiary level medical services has been clearly delineated, the primary level of medical care has been formed, and electronic document management in the health care system has been completed.

A Cross-Sectional Study Examining the Effects of Patient Information Level on Healthcare Experience in 2 Patient Populations: Extranodal Natural Killer T-Cell Lymphoma (ENKTL) and Waldenstrom Macroglobulinemia (WM)

Introduction In recent years, healthcare reform strategies have encouraged patients to become more participatory in the effective management of their health and healthcare. Knowledge dissemination is required to incite and sustain this shift, and there is a growing body of evidence pointing to better outcomes for more 'informed' patients. In 2018, the Lymphoma Coalition (LC) analysed data from the 2018 LC Global Patient Survey (GPS) on Lymphomas and CLL and determined that 'adequately informed' patients reported more positive healthcare experiences. To further assess this correlation, the LC compared 2 patient subpopulations: Extranodal Natural Killer T-cell lymphoma (ENKTL) patients, and Waldenstrom Macroglobulinemia (WM) patients. Both of these rare subtypes present complicated disease landscapes for patients to navigate as they are difficult to understand, treat, and manage. However, 2018 LC GPS results indicated that across all lymphoma subtypes (14 analysed), ENKTL patients reported being the least informed and WM patients the most. The LC compared how this affected patient understanding, patient-doctor communication, and psychosocial side effects. Methodology This study is a sub-analysis of the 2018 LC GPS, which was available in 19 languages and was hosted on a third-party portal from January-March 2018. Globally, there were 6631 participants. Raw data was entered, merged, and cleaned in IBM SPSS v21. The least (ENKTL n=177) and most (WM n=764) informed lymphoma subtypes (lowest and highest proportion of 'adequately' informed patients, respectively) were identified and demographics were compared. Comparison of the subgroup of patients who reported either having the 'most' or the 'least' understanding of key issues surrounding diagnosis and care was completed. Comparison of the subgroup of patients who reported either 'yes' or 'somewhat/no' to questions about patient-doctor communication was completed. The prevalence of psychosocial issues during and after treatment was compared. Differences in proportions were tested using chi-square tests (p=0.05) and odds ratios with 95% CI. Results Of all subtypes analysed, the ENKTL subgroup had the highest proportion of inadequately informed patients (35%), and the lowest proportion of adequately informed patients (13%). The WM subgroup had the highest proportion of adequately informed patients (57%) and the lowest proportion of inadequately informed patients (9%). Both subtypes used the same primary information sources (doctor and websites) and sought information within the same time-span (immediately upon diagnosis). ENKTL and WM patients differed significantly in distribution of age, sex, and residence (all p values <0.05) (table 1). The majority (97%) of ENKTL patients lived in Asia, while the majority (72%) of WM patients lived in North America (NA). Analysis of level of understanding of key issues after patient's initial doctor's appointment showed that compared to WM patients, ENKTL patients were nearly twice as likely to have less understanding of their diagnosis, initial treatment, and different treatment options (OR=1.94, 1.99, 1.84 respectively) (table 2). Compared to ENKTL patients, a greater proportion of WM patients reported having a very good understanding across all issues. Analysis of patient-doctor communication showed that compared to WM patients, ENKTL patients were more likely to not (somewhat/no) communicate all of the issues analysed (table 3). ENKTL patients were twice as likely as WM patients to not communicate medical issues (OR=2.20) and to not seek clarification on things they did not understand (OR=2.28). ENKTL patients were 4 times as likely as WM patients to not feel confident voicing concerns (OR=4.43). Compared to WM patients, the reported prevalence of all psychosocial issues (both during and after treatment) was higher for ENKTL patients (figures 1&2). Changes in relationships and fear of relapse were top reported concerns for both subtypes. ENKTL patients were particularly affected by stress related to finances. Conclusion Compared to ENKTL patients (least informed subtype group in the GPS), WM patients (most informed) reported improved understanding and patient-doctor communication, and lesser prevalence of psychosocial issues. In the future, LC plans to investigate the potential confounding effects of the demographic factors (particularly age) and cultural factors (Asia vs NA). Disclosures No relevant conflicts of interest to declare.

Healthcare Decision-Making Among Dual-Eligible Immigrants: Implications from a Study of an Integrated Medicare-Medicaid Demonstration Program in California.

To improve the coordination of long-term services and supports for dual-eligibles (those with both Medicare and Medicaid), California created Cal MediConnect (CMC), an Affordable Care Act-authorized managed care demonstration program. Beneficiaries were "passively enrolled" into CMC, meaning they were automatically enrolled unless they actively opted out. The aim of this study was to examine differences in factors influencing the enrollment decisions of U.S. born and immigrant dual-eligible beneficiaries. To explore differences in decision-making processes, we conducted in-depth interviews with dual-eligible consumers (39 native and 14 immigrant) in Los Angeles County. Interviews were analyzed using a constructivist grounded theory approach. Our findings illustrate a heightened sense of vulnerability and disempowerment experienced by immigrant participants. Immigrant participants also faced greater challenges in accessing healthcare and eliciting healthcare information compared to U.S.-born participants. Understanding the diverse perspectives of dual-eligible immigrant healthcare decision-making has implications for health care reform strategies aimed at ameliorating disparities for vulnerable immigrant populations.

“Pay for Reporting” and PQRS: The American Quest for Value in Healthcare

Journal of General and Family MedicineVolume 17, Issue 3 p. 191-200 Special ArticlesOpen Access “Pay for Reporting” and PQRS: The American Quest for Value in Healthcare Andrew G. Ten Have MD, MPH, ABFM, Corresponding Author Andrew G. Ten Have MD, MPH, ABFM atenhave@gmail.com Corresponding author: Andrew G. Ten Have, MD, MPH, ABFMDirector of Clinical Training, Kawasaki Saiwai HospitalE-Mail: atenhave@gmail.comSearch for more papers by this author Andrew G. Ten Have MD, MPH, ABFM, Corresponding Author Andrew G. Ten Have MD, MPH, ABFM atenhave@gmail.com Corresponding author: Andrew G. Ten Have, MD, MPH, ABFMDirector of Clinical Training, Kawasaki Saiwai HospitalE-Mail: atenhave@gmail.comSearch for more papers by this author First published: 27 September 2016 https://doi.org/10.14442/jgfm.17.3_191AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1U.S. Department of Health and Human Services. Official Healthcare Blog posted March 23, 2015: Celebrating 5 Years: The Personal Stories Behind the Affordable Care Act Numbers. Available at http://www.hhs.gov/healthcare/facts/blog/2015/03/celebrating-5-years-personal-stories-behind-aca.html Accessed on 4/12/2015. 2OECD. “Life expectancy at birth” in OECD, Health at a Glance 2013: OECD Indicators, OECD Publishing, Paris. Available at http://dx.doi.org/10.1787/health_glance-2013-5-en. Accessed on 2015/03/05. 3OECD. “Infant mortality” in OECD, Health at a Glance 2013: OECD Indicators, OECD Publishing, Paris. Available at http://dx.doi.org/10.1787/health_glance-2013-11-en. Accessed on 2015/03/05. 4University of Washington's Institute for Health Metrics and Evaluation, IHME Data Visualizations; Available at http://vizhub.healthdata.org/le/ accessed on 2015-06-20. (Authorization available at http://www.healthdata.org/about/terms-and-conditions/.) 5Berwick DM, Nolan TW, Whittington J: The triple aim: care, health, and cost. 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Available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/Potential_General_Surgery_Preferred_Specialty_Measure_Set.pdf Accessed on 2105/02/14. 14Centers for Medicare and Medicaid Services. 2013 eRx and PQRS Experience Report. Available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013_PQRS_eRx_Experience_Report_zip.zip Accessed on 2015/06/04. 15Porter ME: A Strategy for Health Care Reform — Toward a Value-Based System. N Engl J Med. 2009; 361: 109– 112. 16Porter ME, Lee TH: Why strategy matters now. N Engl J Med. 2015; 372: 1681– 1684. 17Lee TH: Putting the value framework to work. N Engl J Med. 2010; 363: 2481– 2483. 18Berenson RA, Kaye DR: Grading a physician's value — the misapplication of performance measurement. N Engl J Med. 2013; 369: 2079– 2081. 19Antos JR: Health Care Reform after the ACA. N Engl J Med. 2014; 370: 2259– 2261. 20Cassel CK, Jain SH: Assessing individual physician performance: does measurement suppress motivation? JAMA. 2012; 307(24): 2595– 2596. 21Goitein L: The argument against reimbursing physicians for value. JAMA Intern Med. 2014; 174(6): 845– 846. 22Lindenauer PK, Lagu T, Ross JS, et al: Attitudes of hospital leaders toward publicly reported measures of health care quality. JAMA Intern Med. 2014; 174(12): 1904– 1911. 23National Research Council and Institute of Medicine. (2013). U.S. Health in International Perspective: Shorter Lives, Poorer Health. Panel on Understanding Cross-National Health Differences Among High-Income Countries, Steven H. Woolf and Laudan Aron, Eds. Committee on Population, Division of Behavioral and Social Sciences and Education, and Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: The National Academies Press. Volume17, Issue3September 2016Pages 191-200 ReferencesRelatedInformation

Interprofessional collaboration in health care: Lessons to be learned from competitive sports.

Improved health care collaboration has been cited as a key strategy for health care reform.1,2 Collaboration in health care has been shown to improve patient outcomes such as reducing preventable adverse drug reactions,3,4 decreasing morbidity and mortality rates5,6 and optimizing medication dosages.7 Teamwork has also been shown to provide benefits to health care providers, including reducing extra work4 and increasing job satisfaction.8 As a fourth-year pharmacy student at the University of Saskatchewan (BB), I have noticed this shift becoming increasingly evident in our education, with the incorporation of interprofessional-based learning activities and relocation to a recently built health sciences building. Having played competitive hockey for about 15 years, I have been on both highly successful teams that went on to win championships, as well as teams that were unable to function effectively. What was it about these teams that contributed to our successes or failures? Moreover, can these lessons be extrapolated to health care teams? Characteristics have been identified in both sports and health care that may influence team success.2,9 Examples include accountability, communication, leadership, discipline, coordination, having a clear purpose and having a strategy in place. While a cooking recipe may consist of many ingredients (some perhaps to add flavour; others for consistency), a few ingredients will always remain essential. Reflecting on my experiences as an athlete and as a pharmacy student, 5 key ingredients seem necessary for success in a collaborative team (Table 1). Table 1 Five essential ingredients for team success

Survey of twelve children’s hospital-based accountable care organizations

Accountable care organizations (ACOs) are a primary focus of value-based healthcare reform strategies, however research is lacking on pediatric-specific ACO development. To present the current landscape of children’s hospital-based pediatric ACOs, researchers conducted semi-structured telephone interviews with executive-level staff from twelve ACOs from November 2013 to February 2014. Interview questions spanned five topics: (1) pathway/strategy; (2) organizational structure; (3) shared savings; (4) provider network; (5) data and quality. Three qualitative frameworks were applied to assess the degree of similarity among pediatric ACO models and between these and promulgated adult ACO components: (1) operational diagrams; (2) spectrums of characteristics; (3) financial and organizational categorization. Organizational structures consisted of five Physician-Hospital Organizations, two System-Based Pediatric Contracts, three Provider-Sponsored Managed Care Organizations, and two Hospital Medical Staff Organizations. Oversight models developed for the ACOs included six separate boards, two board subcommittees, and one dispersed governance. Financial contracts between payers and participants included four shared savings only, one risk corridor, and seven full capitation. Eight participants had provider incentive programs primarily for cost reductions. Nine participants used National Committee for Quality Assurance (NCQA)’s Healthcare Effectiveness Data Information Set (HEDIS) metrics, emphasized utilization management, and invested in separate care coordination resources. Overall, marked variation in pediatric ACO models is developing nationally, and cost savings goals exceed the importance of quality improvement. National pediatric collaboration and state facilitation for ACO quality measures is crucial to improving health outcomes in the pediatric ACO.

European hospital reforms in times of crisis: Aligning cost containment needs with plans for structural redesign?

Hospitals have become a focal point for health care reform strategies in many European countries during the current financial crisis. It has been called for both, short-term reforms to reduce costs and long-term changes to improve the performance in the long run. On the basis of a literature and document analysis this study analyses how EU member states align short-term and long-term pressures for hospital reforms in times of the financial crisis and assesses the EU's influence on the national reform agenda. The results reveal that there has been an emphasis on cost containment measures rather than embarking on structural redesign of the hospital sector and its position within the broader health care system. The EU influences hospital reform efforts through its enhanced economic framework governance which determines key aspects of the financial context for hospitals in some countries. In addition, the EU health policy agenda which increasingly addresses health system questions stimulates the process of structural hospital reforms by knowledge generation, policy advice and financial incentives. We conclude that successful reforms in such a period would arguably need to address both the organisational and financing sides to hospital care. Moreover, critical to structural reform is a widely held acknowledgement of shortfalls in the current system and belief that new models of hospital care can deliver solutions to overcome these deficits. Advancing the structural redesign of the hospital sector while pressured to contain cost in the short-term is not an easy task and only slowly emerging in Europe.

Specialties: Missing in Our Healthcare Reform Strategies?

Given the amount of frenetic healthcare reform preparation occurring with accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and bundling demonstrations, are we overlooking—or quietly ignoring—medical and surgical specialists and subspecialists in our planning? It may seem to specialists that they are off the healthcare radar screen for now. Yes, a few medical homes and ACOs are specialty based, and some commercial health plans and for-profit entities are creating accountable care scenarios with specialists in oncology, end-stage renal disease (ESRD), and a few other medical conditions. Bundled payment demonstration projects are frequently identified with specialists, but in reality these payment models currently fit some specialties better than others. Specialists account for the majority of U.S. physicians, but the actual number of physicians involved in these initiatives is only a small percentage of the specialty workforce. Most specialists are independent and are not hospital based or hospital employed. Even if the organizations where they practice are working with ACO, PCMH, or bundling models, they are not often directly involved. Over the years, healthcare executives have been careful not to rock the boat with specialists or disturb their productivity under hospital roofs. But aren't they a major part of healthcare reform strategies? Realize that they have a tremendous ability to change clinical costs and outcomes and to significantly affect local market dynamics. Specialists and their practice administrators have been asking what role they play in ACOs and PCMHs. They are not seeking alternatives to fee-for-service (FFS) but, at a minimum, want to be a player at the table for the new payment models to avoid losing future referrals. The Centers for Medicare & Medicaid Services has not developed a Medicare Shared Savings Program model for specialty care (although ESRD initiatives are in the works), which is understandable, given the significant risk and complexity associated with managing smaller pools of more vulnerable patient populations. Then how do ACO and PCMH referrals differ from routine patient visits? Currently, they don't. Unless the specialists are in a demonstration project or have an arrangement with a commercial insurer, specialty referrals generate FFS compensation, not a value-based payment.

Use of radiation pathways to drive standardization of evidence-based care across a large network.

27 Background: UPMC CancerCenter includes 37 academic and community based sites in western Pennsylvania. Consistency and quality of care are critical to such a diverse network. To meet these challenges, UPMC developed clinical pathways for medical and radiation oncology, now marketed as Via Pathways. The program has served UPMC well for over eight years and is now a key foundation for UPMC’s overall healthcare reform strategy for accountable care. Methods: Radiation treatment algorithms for 90% of cancers were developed by committees of academic and community radiation, surgical, and medical oncologists, with current representation from multiple cancer centers across the country. The committees meet semi-annually to interpret the literature and define the most efficacious and least toxic treatments for highly specific disease presentations (e.g., oropharynx, Stage III-IV, primary chemoradiation). Guidance for contouring, planning and delivery are provided along with applicable citations. Clinical trials open at UPMC sites are also imbedded into the algorithms. Converting these algorithms into measureable decision support is accomplished with a web portal that presents the individual pathways status through the physician’s daily schedule. Results: Thirty-one (31) radiation oncologists at UPMC use Via Pathways in their daily practice. For the 12 months ended May 31, 2013, UPMC physicians confirmed a pathways status for 98% of their patient visits (n=9,400) and achieved an On Pathway rate of 95% for their 5,575 treatment decisions. All off pathway treatment decisions were approved prior to treatment by a designated peer review radiation oncologist within UPMC. Reasons for going off pathway were recorded as well as what alternative approach to care was chosen. Conclusions: When appropriately developed and implemented, clinical pathways are a solution to standardizing care across multiple sites and physicians with the potential to improve the quality and cost effectiveness of cancer care. We continue to expand the scope of Via Pathways to include additional cancer types, surveillance protocols, and end of life prompts as well as surgical oncology pathways.

Using a pathways process to ensure measurable evidence-based standardized care in a large cancer network.

252 Background: UPMC CancerCenter includes 40 sites of services in a 100 mile radius in Western Pennsylvania. Consistency and quality of care are critical to such a diverse network. In addition, the UPMC mission includes accrual to clinical trials. To meet these challenges, UPMC developed the Via Oncology Pathways. The program has served UPMC well for over seven years to date and is now a key foundation for UPMC’s overall healthcare reform strategy for quality and accountable care. Methods: Treatment algorithms were developed for 90% of cancer types by establishing committees of academic and community specialists. These committees interpret the literature and define the most efficacious, least toxic, and economically efficient treatment regimens appropriate for highly specific disease presentations (e.g., node +, er-, her2 +, PS 0-1). Clinical trials are also imbedded into the algorithms. Quarterly, these algorithms are reviewed by the committees to assess relevance, review network feedback, add newly available trials and address emerging data. Equally important to clinical content is its presentation to the practicing physician in a manner that allows real time usage and adds value to physician workflow. This is accomplished with a web portal that presents the individual pathways status through the physician’s daily schedule. Results: Over 120 oncologists at UPMC use Via Oncology Pathways in their daily practice. In 2011, UPMC physicians confirmed a pathways status for 94% of their patient visits (195,000) and achieved an On Pathway rate of 82% for their 18,000 treatment decisions. The database also includes patient presentations, reasons for going off pathway and reasons for not accruing to clinical trial. Lower hospitalization rates and mandated adoption of personalized medicine were also observed. Conclusions: When appropriately developed and implemented, clinical pathways are a solution to improving the quality and cost effectiveness of cancer care by enhancing physician decision-making, standardizing care and ensuring access to evidence-based personalized medicine. We continue to expand the scope of our pathways to include diagnostic studies, surveillance protocols and end of life prompts.

ACOs Predicted to Survive Health-Reform Battle

Washington – They may seem futuristic, but accountable care organizations (ACOs) already number more than 250 in the United States. The health care–delivery model, based on a team approach to patient-centered care, is supposed to control costs while maximizing quality. ACOs hit the big time as a featured strategy for health care reform in the 2010 Accountable Care Act. But what would the unraveling of President Obama’s health care reform mean to ACOs? Speaking just before the U.S. Supreme Court delivered its decision that the act is constitutional, Mark McClellan, PhD, a director of the Centers for Medicare & Medicaid Services under President George W. Bush, predicted that even in a Mitt Romney administration and a Republican-dominated Congress, ACOs will have a place. “ACOs, which support better care at lower costs, are more likely to help our health care system operate more efficiently,” said Dr. McClellan, now director of the Engelberg Center for Health Care Reform at The Brookings Institution. “The question is not whether ACOs will continue but how we can make the work of ACOs more impactful.” Dr. McClellan pointed out that the reforms carried by the ACO model are backed by many physicians.

“This Drug May Work, But Is It Worth the Cost?” Can Comparative Effectiveness Research Help Tame Rising Health Care Costs?

“This Drug May Work, But Is It Worth the Cost?” Can Comparative Effectiveness Research Help Tame Rising Health Care Costs?

Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems.

BackgroundA commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments’ healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money.MethodsCritical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England’s National Health Service’s Care Records Service (NHS CRS).Results/discussionWe advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations → intervention → changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions.SummaryNew and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.

Community Health Development: A Strategy for Reinventing America’s Health Care System One Community at a Time

The purpose of this article is to propose a set of ideas for reinventing America's health care system, one community at a time. Community health development is proposed as a strategy and approach to population health improvement, the ultimate goal of health care reform. The practice of community health development, particularly the partnership approach, provides guidance about how this approach might be employed as a national health care reform strategy. Examples of two communities successfully using the partnership approach illustrate the methods described. Six specific recommendations for policy makers and public administrators in the new administration resulting from our experience with community health development are presented. First, adopt and apply community health development (CHD) as the American approach for facilitating population health improvement and building community capacity. Second, the partnership approach should be promoted as a model for communities to use in implementing CHD. Third, make the community-level the focus for planning, implementing, evaluating, and sustaining a full continuum of health and human services. Fourth, formally recognize the social determinants of health as a key component of a new population/community health status model and as a public policy driver for health care reform, marketplace issues, and population health status improvement at all levels of society. Fifth is a call for a national strategy for the recruitment, training, education, and support of individuals to facilitate this community movement. Sixth, Congress and the Obama Administration adopt and apply CHD as a national strategy and utilize American community-based experiences to bring about a national plan.

Comparative effectiveness research: evidence‐based medicine meets health care reform in the USA

Rationale Comparative effectiveness research (CER) is the study of two or more approaches to a health problem to determine which one results in better health outcomes. It is viewed by some in the USA as a promising strategy for health care reform. Aims and Objectives In this paper, nascent US CER policy will be described and analysed in order to determine its similarities and differences with EBM and its chances of success. Methods Document review and process tracing Results CER shares the logic of policies promoting evidence-based medicine, but invites greater methodological flexibility to ensure external validity across a range of health care topics. Conclusions This may narrow the inferential distance from knowledge to action, but efforts to change the US health care system through CER will face familiar epistemological quandaries and 'patient-centred' politics on the left and right.

Consumer‐Oriented Health Care Reform Strategies: A Review of the Evidence on Managed Competition and Consumer‐Directed Health Insurance

For many years, leading health care reform proposals have been based on market-oriented strategies. In the 1990s, a number of reform proposals were built around the concept of "managed competition," but more recently, "consumer-directed health care" models have received attention. Although price-conscious consumer demand plays a critical role in both the managed competition and consumer-directed health care models, the two strategies are based on different visions of the health care marketplace and the best way to use market forces to achieve greater systemwide efficiencies. This article reviews the research literature that tests the main hypotheses concerning the two policy strategies. Numerous studies provide consistent evidence that consumers' health plan choices are sensitive to out-of-pocket premiums. The elasticity of demand appears to vary with consumers' health risk, with younger, healthier individuals being more price sensitive. This heterogeneity increases the potential for adverse selection. Biased risk selection also is a concern when the menu of health plan options includes consumer-directed health plans. Several studies confirm that such plans tend to attract healthier enrollees. A smaller number of studies test the main hypothesis regarding consumer-directed health plans, which is that they result in lower medical spending than do more generous plans. These studies find little support for this claim. The experiences of employers that have adopted key elements of managed competition are generally consistent with the key hypotheses underlying that strategy. Research in this area, however, has focused on only a narrow range of questions. Because consumer-directed health care is such a recent phenomenon, research on this strategy is even more limited. Additional studies on both topics would be valuable.