Recommended
Recommended
More Related Content
Similar to Running Head HEALTHCARE STAKEHOLDER CONFLICTS1HEALTHCARE .docx
Similar to Running Head HEALTHCARE STAKEHOLDER CONFLICTS1HEALTHCARE .docx (20)
More from cowinhelen
More from cowinhelen (20)
Recently uploaded
Recently uploaded (20)
Running Head HEALTHCARE STAKEHOLDER CONFLICTS1HEALTHCARE .docx
- 1. Running Head: HEALTHCARE STAKEHOLDER CONFLICTS 1 HEALTHCARE STAKEHOLDER CONFLICTS 5 Stakeholder Conflicts in Healthcare Visions Kendra Smith Grand Canyon University: HCA 675 Introduction The stakeholders in the healthcare service in any jurisdiction entail the government, the healthcare providers or the physicians, the payers, the patients as well as healthcare professional organizations. These stakeholders work hand in hand to ensure efficiency and professionalism in healthcare delivery (Blair et al, 1988). They do this by developing succinct policies and effectively implement them for the sole purpose of improving healthcare services. However, there have been serious conflicts in opinion regarding enhancing healthcare service practices and proper administrative mechanisms for the achievement of better services, among the stakeholders. Conflicts in Health Vision One of the major health reform visions which have generated considerable debate concerns the accommodation of evidence- driven healthcare service practice, which the government of the United States has instructed all healthcare service providers or organizations to adopt. The major emphasis on this aspect of medicine is the requirement by the government that all
- 2. healthcare service providers or organizations should document which healthcare services they provide and why they provide such healthcare services to the communit y. The argument behind this requirement is that it will enable the government, or it will be generally helpful in gauging the benefits the community gains from such healthcare services. In addition, establishing evidence-driven healthcare practice according to healthcare practitioners will help in identifying specific health problems within a community, and subsequently, design the most appropriate medical response. Some healthcare stakeholders also believe that this is an avenue that the government intends to use in creating and forging a closer working relationship between private and public healthcare providers. However much most stakeholders, both private and public, appreciate this evidence-based healthcare practice, as a vital component in improving healthcare services, the major concern is about how such data should be obtained. Some healthcare providers have reasoned that these data should be generated from the already existing data, due to the costs associated with activities that may lead to acquiring and establishing sound data or information domain. In response to this requirement, most of the healthcare organizations have established community-based information or data collection and management mechanisms, which enable them to collect data concerning community health concerns and threats, then define effective ways of response. With the introduction and implementation of a series of healthcare reforms in the United States, such as the Obamacare and Trumpcare, there is general expectation that there will be enhanced access to healthcare services due to the expansion of the Medicaid and other healthcare insurance covers to support most of the healthcare needs of the American citizens (Berwick et al, 2008). However, this vision has generated serious conflicts among
- 3. stakeholders. Firstly, there has been a concern on how the increase in the number of patients who will be seeking healthcare service, due to the expansion of healthcare access should be handled by stakeholders (Skinner et al, 2007 ). This issue has led stakeholders into questioning whether the good.hospital facilities do have the capacity, both in terms of sufficient human resource availability and structural space, to effectively provide the healthcare services and a accommodate their clients (Skinner et al, 2007). This healthcare administrative concern is also linked to how the healthcare services will be coordinated under such congested systems as well as how payments for health care services rendered shall be remitted to the hospitals. In view of this concerns, certain healthcare facilities or organizations have rolled-out home-based nursing or healthcare programs or plans, as a mechanism of reducing congestion in the facilities, even though this may not be 100% effective due to considerable communication, transport, and other logistical issues. Secondly, the health reforms of universal healthcare access have also introduced management or administrative concerns within the healthcare facilities or organizations (Beaussier et al, 2014). The government of the United States expects healthcare organizations to provide quality services at a cheaper cost. The center of ideological conflict among stakeholders with regard to this aspect of quality-cheap healthcare services has always been how the related health administrative costs shall be shouldered. For instance, the private healthcare organizations-which by very nature do not receive financial support from the government, have raised concerns how the government expects them to roll- out an effective, quality and cheap healthcare services to patients without financial support (Beaussier et al, 2014 ). Some of these organizations have been compelled, by
- 4. prevailing financial circumstances, to lay out some of their staff and suspend other costly health programs in order to reduce operation expenses as they endeavor to meet the requirement of cheap-quality healthcare service policy as provided in the reform agenda, by the government of the United States. Some private healthcare organizations have alternatively closed down, due insufficient funds to fully and effectively roll-out and sustain the requirements of the policy. Thirdly, another source of conflict among healthcare stakeholders with regard to the healthcare insurance or Medicaid reforms has been about the fiscal outlook of the United States of America. The question has been whether the government will be in a position to effectively and sufficiently support and sustain the program (Skinner et al, 2007). With the broadening of the Medicaid coverage eligibility, and the undertaking by the federal government, as a stakeholder, to finance the entire additional costs, other stakeholders have consistently opined that State governments may not be in a position to effectively and sufficiently support or finance their Medicaid responsibilities, due to the fact that the healthcare services budget has been consistently bulging to an extent that it can no longer be effectively sustained, due to economic recessions which often hit some of the states. Fourthly, concerning healthcare accessibility as permeated in the reforms, another eminent and legitimate concern is about the fate of those who shall not be covered under the new healthcare insurance reforms due to financial constraints, generally referred to as the uninsured (Berwick et al, 2008). The state and other stakeholders are gambling to address this concern, in the face of serious glaring concerns. Some stakeholders have argued that the uninsured persons, under the new healthcare reforms, may have their health care needs cared for by "already existing healthcare systems". However, stakeholders argue that this concern has not been adequately and sufficiently addressed by the government, and some healthcare organizations have
- 5. reported cases of either not offering healthcare services to the uninsured patients or alternatively offering partial healthcare service to such patients . Conclusion In responding and solving the eminent conflicts regarding health policies and reforms, the stakeholders in the healthcare sector should have concrete health care reform implementation processes, which creates and enhances the understanding of each and every stakeholder. This will be important so as not to hamper the provision of healthcare services to the citizens. References Blair, J. D., & Whitehead, C. J. (1988). Too Many On The Seesaw: Stakeholder Diagnosis And Managemen. Journal of Healthcare Management, 33(2), 153. Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: care, health, and cost. Health Affairs, 27(3), 759- 769. Beaussier, A. L., & Raillard, S. L. (2014). American Health Care Policy in a Time of Party Polarization. Revue française de science politique, 64(3), 383-405. Skinner, J., Fisher, E. S., & Wennberg, J. E. (2007). The Efficiency of Medicare. Analyses in the Economics of Aging, 129. Edwards, R. (2010). Access. (Cover story). H&HN: Hospitals & Health Networks, 84(8), 16-19. Birk, S. (2010). The evidence-based road: available data can drive successful community benefit programs. Healthcare Executive, 25(4), 28-36. Hello Kendra, good attempt to do this assignment but you did not clearly answer all parts of the question which is write a
- 6. paper to “compares and contrasts the competing visions of health care administration among stakeholders, identifies the areas where they conflict, and discusses how those conflicts could be seen in the delivery system.” There are three parts to this question: 1. Compare and contrasts the competing visions of health care administration among stakeholders 2. Identify the areas where they conflict 3. Discuss how those conflicts could be seen in the delivery system. In your paper you mainly discussed conflicts I in the healthcare system. Also, most of the first part of your paper was not supported by any in text citation. Please see my comments inserted in your paper. have attached a copy of GCU’s guidelines under the Resourses Tab –ADD ONNS in the classroom. Please note the answers to this assignment are in the study notes which you did not reference. Continue to work hard. Radha �Kendra, please not according to GCU guidelines located under the Resources Tab in the classroom, under ADD ONNs I attached GCU guidelines on the APA format. It states “<Note: Even though APA does not require the �date on a title page, it is a requirement for GCU papers.>� �Good thesis statement but needs improvement.
- 7. According to the grading rubric a thesis statement should be comprehensive and convey the gist of the paper. �It is important to support the contents of your paper with credible references. It gives credit to the author, allows you to claim ownership of your work and avoid plagiarism. �You paper is informative but who says so? Are they you thoughts or are they of an author? �Excellent! you have a credible reference to support a very important point. � �? �Good example. �Good discussion. �Relevant information. �Overall, good conclusion
- 8. Sheet1USA Civilian labor force & unemployment by metropolitan area - August 2017* preliminary, not seasonally adjustedCivilian labor forceUnemployed NumberUnemployed PercentState and area20162017 *20162017 *20162017 *Alabama2,168,4602,162,768134,75492,8376.24.3Anniston- Oxford-Jacksonville45,78745,3933,1232,2086.84.9Auburn- Opelika73,35273,7844,0182,8535.53.9Birmingham- Hoover535,382533,08431,32120,9235.93.9Daphne-Fairhope- Foley91,33892,2914,9523,4835.43.8Decatur68,80268,6114,1212 ,83164.1Dothan62,85262,3293,8772,6506.24.3Florence-Muscle Shoals66,71665,6034,5233,0636.84.7Gadsden43,53843,7972,72 31,8916.34.3Huntsville212,978216,08111,5318,0825.43.7Mobil e183,688181,10113,0709,3667.15.2Montgomery170,887170,426 10,2077,05664.1Tuscaloosa112,726112,8947,1274,7386.34.2Ala ska366,325369,98221,30123,4305.86.3Anchorage198,924201,96 110,87912,1685.56Fairbanks46,82947,1642,2502,5894.85.5Ariz ona3,243,6833,304,258186,548169,6705.85.1Flagstaff75,06075, 7054,6473,8396.25.1Lake Havasu City- Kingman81,32382,6145,4544,7696.75.8Phoenix-Mesa- Scottsdale2,242,3312,291,662108,75298,2164.84.3Prescott100,4 20102,0825,0104,49854.4Sierra Vista- Douglas50,22950,0383,1342,7846.25.6Tucson466,964470,90824 ,38621,4135.24.5Yuma98,285101,24623,49524,00623.923.7Ark ansas1,345,0361,371,78052,96948,6333.93.5Fayetteville- Springdale-Rogers265,220277,1817,5517,5182.82.7Fort Smith121,797122,2315,6685,2024.74.3Hot Springs40,51041,8881,6921,5754.23.8Jonesboro62,67864,5812, 1102,0493.43.2Little Rock-North Little Rock- Conway353,122359,44812,35411,3843.53.2Pine Bluff36,05236,0162,0591,7475.74.9California19,178,34019,293 ,4971,069,0941,041,4995.65.4Bakersfield390,645391,79537,954 36,7869.79.4Chico101,826103,4246,6366,5606.56.3El Centro77,88576,10921,14118,94727.124.9Fresno449,520448,58 538,12038,3748.58.6Hanford-
- 9. Corcoran57,49957,5025,0554,8988.88.5Los Angeles-Long Beach- Anaheim6,660,7646,737,326353,009344,6945.35.1Madera61,75 562,8145,0544,8768.27.8Merced115,727114,82410,41310,3969 9.1Modesto248,562251,83619,25918,8867.77.5Napa74,55575,9 853,0452,8964.13.8Oxnard-Thousand Oaks- Ventura423,158427,60023,85422,4615.65.3Redding75,26676,90 14,9174,6156.56Riverside-San Bernardino- Ontario1,984,7032,000,869127,530123,5376.46.2Sacramento-- Roseville--Arden- Arcade1,080,2101,084,14557,52655,8725.35.2Salinas228,24822 5,73812,54812,5475.55.6San Diego- Carlsbad1,577,5901,577,61077,77374,2014.94.7San Francisco- Oakland-Hayward2,559,6682,572,031102,243101,30943.9San Jose-Sunnyvale-Santa Clara1,063,9941,062,07842,78041,24443.9San Luis Obispo- Paso Robles-Arroyo Grande138,302138,7016,2956,0044.64.3Santa Cruz- Watsonville145,671145,8988,2927,9315.75.4Santa Maria-Santa Barbara217,146217,04910,38310,0834.84.6Santa Rosa262,967258,55210,45010,06743.9Stockton- Lodi320,922320,44024,40323,9267.67.5Vallejo- Fairfield208,107207,84611,62011,3315.65.5Visalia- Porterville206,315209,66521,36422,16710.410.6Yuba City75,43075,8675,8055,8187.77.7Colorado2,910,5443,009,751 93,70366,6163.22.2Boulder179,961187,7064,9903,6272.81.9Col orado Springs327,448338,56612,1558,7383.72.6Denver-Aurora- Lakewood1,550,8561,608,30247,51534,5953.12.2Fort Collins189,699200,6475,2773,7082.81.8Grand Junction71,82572,2633,6512,1995.13Greeley149,802156,5155,0 893,2593.42.1Pueblo72,33473,7603,4382,6474.83.6Connecticut 1,907,0301,919,37698,95187,4045.24.6Bridgeport-Stamford- Norwalk472,802475,63723,69621,17154.5Danbury108,254109,2 634,6274,0544.33.7Hartford-West Hartford-East Hartford620,032623,46432,90729,0855.34.7New Haven323,996327,05716,99415,0805.24.6Norwich-New
- 10. London- Westerly144,951145,6507,4856,2365.24.3Waterbury111,634111 ,7467,0756,2696.35.6Delaware474,958481,51521,26224,7944.5 5.1Dover76,72877,4043,9214,6215.16Salisbury(1)195,221198,9 049,1959,1444.74.6District of Columbia391,268397,24724,96826,2446.46.6Washington- Arlington- Alexandria3,317,9643,405,922132,301127,49743.7Florida9,867, 35510,127,466509,388430,2335.24.2Cape Coral-Fort Myers324,295326,38715,94713,2814.94.1Crestview-Fort Walton Beach-Destin125,585129,0915,0744,25143.3Deltona- Daytona Beach-Ormond Beach292,907298,28415,56813,1355.34.4Gainesville136,84514 1,1226,2575,3074.63.8Homosassa Springs47,77947,4233,3792,8037.15.9Jacksonville743,945762,4 6537,33431,46154.1Lakeland-Winter Haven286,396292,70417,44714,1906.14.8Miami-Fort Lauderdale-West Palm Beach3,057,0213,140,503163,683140,3985.44.5Naples- Immokalee-Marco Island164,249168,4879,0287,8995.54.7North Port-Sarasota- Bradenton349,026365,29716,74314,2634.83.9Ocala133,694135, 9178,1446,6686.14.9Orlando-Kissimmee- Sanford1,266,2071,307,05359,66349,9704.73.8Palm Bay- Melbourne-Titusville265,194271,68314,06911,6135.34.3Panama City95,94797,0634,5913,8374.84Pensacola-Ferry Pass- Brent220,030224,00810,8188,9274.94Port St. Lucie205,557210,21012,0779,9685.94.7Punta Gorda69,02871,1033,8413,3085.64.7Sebastian-Vero Beach61,88763,2894,2633,4716.95.5Sebring35,52936,9232,533 2,1517.15.8Tallahassee186,972191,7169,3547,63254Tampa-St. Petersburg-Clearwater1,481,7201,526,00771,47660,5144.84The Villages29,34130,2462,0971,8107.16Georgia4,920,8335,057,57 3273,846242,5705.64.8Albany65,66066,7604,3243,8756.65.8At hens-Clarke County97,33699,6455,3094,6645.54.7Atlanta- Sandy Springs-
- 12. Lafayette108,006109,5874,5104,2554.23.9Michigan City-La Porte48,56746,9002,7622,2905.74.9Muncie54,10854,2582,8592, 7835.35.1South Bend- Mishawaka155,486154,3937,3566,6104.74.3Terre Haute77,28378,1554,1693,7075.44.7Iowa1,702,4361,687,99362, 72054,8853.73.3Ames54,83055,7521,4251,3602.62.4Cedar Rapids143,042142,1775,3895,0613.83.6Des Moines-West Des Moines346,434351,29211,88610,4813.43Dubuque53,96653,390 1,9341,6753.63.1Iowa City97,68398,9512,7692,8172.82.8Sioux City92,73191,1103,2462,9453.53.2Waterloo-Cedar Falls89,15586,9294,1993,2804.73.8Kansas1,477,6861,481,4586 7,29661,6274.64.2Lawrence62,70763,5412,5372,33443.7Manhat tan45,39846,4151,7471,5983.83.4Topeka121,375122,0325,2494 ,9214.34Wichita309,168310,59016,17514,7825.24.8Kentucky1, 990,0542,054,26395,780106,2244.85.2Bowling Green78,51482,1912,9293,8543.74.7Elizabethtown-Fort Knox65,46768,3882,7453,3194.24.9Lexington- Fayette260,925270,5839,02010,8313.54Louisville/Jefferson County646,320669,71926,56129,8264.14.5Owensboro53,55055, 3212,2462,7454.25Louisiana2,118,7942,091,226138,745117,990 6.55.6Alexandria66,08564,5604,5064,0406.86.3Baton Rouge415,368416,47523,65520,6215.75Hammond54,73054,317 3,8863,4397.16.3Houma- Thibodaux91,87188,3126,5535,0687.15.7Lafayette215,408209,5 1616,20712,4987.56Lake Charles107,096111,1245,4794,7805.14.3Monroe80,86180,3765, 2804,5076.55.6New Orleans- Metairie600,382593,57035,93032,06365.4Shreveport-Bossier City191,345185,91313,28811,3086.96.1Maine710,951721,38823 ,40022,1813.33.1Bangor70,10371,1112,4052,3273.43.3Lewiston -Auburn55,80357,0461,7941,7393.23Portland-South Portland207,674214,0945,4815,3472.62.5Maryland3,191,3653,2 64,773139,987131,4304.44Baltimore-Columbia- Towson1,494,1891,525,20368,79264,8184.64.2California- Lexington Park54,90156,0632,3922,2914.44.1Cumberland44,12043,8532,7
- 14. Joseph66,38964,7123,0142,4394.53.8St. Louis(2)1,485,0531,467,78776,32060,4125.14.1Springfield230, 005230,09610,8388,2244.73.6Montana534,042532,86919,67217 ,8743.73.4Billings88,14188,5283,0662,8153.53.2Great Falls37,99738,1661,3651,2683.63.3Missoula61,02961,2322,017 1,8933.33.1Nebraska1,013,6731,010,47332,82127,9963.22.8Gra nd Island43,54043,7661,4431,1943.32.7Lincoln176,491181,1745,2 844,56132.5Omaha-Council Bluffs478,379486,18216,22814,0223.42.9Nevada1,429,1731,44 9,76779,02472,2395.55Carson City24,87724,7551,3991,1585.64.7Las Vegas-Henderson- Paradise1,049,1011,068,80260,13755,9015.75.2Reno232,45223 4,78810,8979,5354.74.1New Hampshire758,169757,79820,93319,4372.82.6Dover- Durham83,99584,3102,1521,9762.62.3Manchester116,381117,1 233,2183,0192.82.6Portsmouth77,56176,2751,8861,7782.42.3N ew Jersey4,545,1234,553,480229,302218,42154.8Atlantic City- Hammonton126,672127,1738,4148,4056.66.6Ocean City56,89057,0003,1252,9595.55.2Trenton200,027201,0249,242 8,8144.64.4Vineland- Bridgeton65,04966,6074,7994,7327.47.1New Mexico928,217924,41366,05159,5857.16.4Albuquerque422,900 422,68327,77825,9066.66.1Farmington52,51850,6745,2503,878 107.7Las Cruces95,16195,1106,8596,4237.26.8Santa Fe73,16073,6834,1913,9795.75.4New York9,627,1049,730,139474,278473,0174.94.9Albany- Schenectady- Troy449,313449,24318,05818,87344.2Binghamton107,904108,2 295,3695,45855Buffalo-Cheektowaga-Niagara Falls549,644549,78727,14928,5884.95.2Elmira36,09735,7301,9 621,8665.45.2Glens Falls63,21963,0672,5692,6084.14.1Ithaca49,05648,6012,0512,1 554.24.4Kingston88,45088,9733,9584,0414.54.5New York- Newark-Jersey City10,046,93910,160,481503,205488,28554.8Rochester521,23
- 17. Bluffton-Beaufort87,17087,9284,1063,5874.74.1Myrtle Beach- Conway-North Myrtle Beach196,941198,37310,4259,2275.34.7Spartanburg154,660157 ,1117,6156,9564.94.4Sumter44,30544,2012,6402,54565.8South Dakota458,179462,68212,51015,6492.73.4Rapid City75,30376,8942,0492,5612.73.3Sioux Falls146,631150,4233,2344,2282.22.8Tennessee3,149,6003,193, 952163,305115,3115.23.6Chattanooga260,265266,73113,93810, 3805.43.9Clarksville109,810111,0146,4545,3225.94.8Cleveland 57,93059,3112,9832,1435.13.6Jackson63,66264,1593,5212,4605 .53.8Johnson City88,70689,2515,0723,6635.74.1Kingsport- Bristol- Bristol137,494138,4357,5785,4975.54Knoxville413,651413,955 20,34114,3814.93.5Memphis623,533630,87634,97726,2625.64.2 Morristown50,63051,4522,8462,0135.63.9Nashville-Davidson-- Murfreesboro-- Franklin977,4311,007,20540,37228,8404.12.9Texas13,295,1711 3,406,779656,216604,7574.94.5Abilene74,26873,6443,0873,030 4.24.1Amarillo130,768131,3764,3364,1053.33.1Austin-Round Rock1,110,4471,126,10838,24137,7613.43.4Beaumont-Port Arthur173,208171,28012,97212,3447.57.2Brownsville- Harlingen166,665167,53012,56912,2667.57.3College Station- Bryan121,186124,0074,9464,4724.13.6Corpus Christi205,014208,21712,80712,1106.25.8Dallas-Fort Worth- Arlington3,699,7563,773,579150,287146,7434.13.9El Paso351,001355,48818,57217,1075.34.8Houston-The Woodlands-Sugar Land3,286,9123,307,745187,888170,5885.75.2Killeen- Temple175,369178,6898,1537,5714.64.2Laredo113,502113,599 5,8484,9525.24.4Longview98,64996,7106,8195,0356.95.2Lubbo ck158,670160,0475,8355,8163.73.6McAllen-Edinburg- Mission333,949335,11727,71326,7108.38Midland86,52286,380 4,0882,7984.73.2Odessa75,44173,9755,3133,17474.3San Angelo54,81653,7072,6042,0584.83.8San Antonio-New Braunfels1,140,4041,156,39445,31843,08143.7Sherman- Denison61,16761,7082,4292,26943.7Texarkana65,15964,5433,2
- 18. 403,03854.7Tyler106,279106,7235,3214,32654.1Victoria47,210 46,6912,8462,26264.8Waco122,920121,9045,2195,4344.24.5Wi chita Falls63,86662,8862,8902,4774.53.9Utah1,521,5141,575,63551,8 1455,2173.43.5Logan65,75167,9402,0582,0523.13Ogden- Clearfield318,958330,13010,84211,7853.43.6Provo- Orem284,735296,7928,8399,6173.13.2St. George68,52672,5582,4202,6893.53.7Salt Lake City641,274663,51120,56122,6733.23.4Vermont348,711349,081 10,91610,4753.13Burlington-South Burlington125,752126,8313,3923,2322.72.5Virginia4,250,8254, 331,940183,143165,2764.33.8Blacksburg-Christiansburg- Radford90,68991,7225,7123,8746.34.2Charlottesville113,74411 6,7644,3854,1013.93.5Harrisonburg63,74064,7612,7392,4964.3 3.9Lynchburg121,582121,5886,0165,6344.94.6Richmond664,35 7687,48729,43627,1734.44Roanoke157,282161,5056,6766,4794 .24Staunton-Waynesboro59,02860,1802,2752,1153.93.5Virginia Beach-Norfolk-Newport News843,713848,23641,07436,6404.94.3Winchester69,87371,0 052,6592,4243.83.4Washington3,658,7703,743,407193,627169, 5835.34.5Bellingham106,052109,6336,4225,1546.14.7Bremerto n-Silverdale116,862118,7396,8115,5365.84.7Kennewick- Richland136,893138,7108,7556,7066.44.8Longview44,75445,51 73,3862,5477.65.6Mount Vernon- Anacortes59,03660,8563,8762,9596.64.9Olympia- Tumwater129,021134,2847,3496,2185.74.6Seattle-Tacoma- Bellevue2,033,6242,077,05690,37686,7824.44.2Spokane- Spokane Valley253,478258,53516,18513,0136.45Walla Walla30,41631,0141,6331,3565.44.4Wenatchee67,90369,9343,6 832,8665.44.1Yakima132,845136,8879,3217,95675.8West Virginia787,513782,24346,85442,0235.95.4Beckley46,55444,70 83,1622,6656.86Charleston97,13197,5815,7215,2725.95.4Hunti ngton- Ashland146,220146,5029,3438,7576.46Morgantown65,23866,18 23,1522,9164.84.4Parkersburg- Vienna39,30138,7532,3632,24165.8Wheeling65,22464,3074,176
- 19. 3,6476.45.7Wisconsin3,144,4473,185,750125,875107,34443.4A ppleton133,252136,8884,6193,9493.52.9Eau Claire92,12591,7073,2092,8983.53.2Fond du Lac57,31758,5542,1051,7603.73Green Bay175,283176,8156,3835,2193.63Janesville- Beloit84,80887,5633,7833,2244.53.7La Crosse- Onalaska77,13678,8542,8022,2683.62.9Madison385,283392,586 10,8909,5362.82.4Milwaukee-Waukesha-West Allis835,493842,46538,89133,2444.73.9Oshkosh- Neenah93,52394,7703,4163,0293.73.2Racine100,909102,6975,3 284,7625.34.6Sheboygan63,34964,0752,0731,7913.32.8Wausau 74,71375,7642,5462,3573.43.1Wyoming304,511296,60214,3221 0,2544.73.5Casper40,68938,8782,7161,7426.74.5Cheyenne48,5 7148,1671,8501,5603.83.2Puerto Rico1,106,7651,096,951133,047128,0541211.7Aguadilla- Isabela88,75489,26913,45313,54015.215.2Arecibo52,49651,223 7,1166,72613.613.1Guayama22,00421,8673,9814,32418.119.8M ayaguez28,80729,1124,0684,03114.113.8Ponce96,55095,40114, 91714,61315.515.3San German36,36837,6835,4046,17414.916.4San Juan-Carolina- Caguas736,634726,49576,14770,47110.39.7https://www.bls.gov /news.release/metro.t01.htmhttps://www.bls.gov/news.release/m etro.t01.htmhttps://www.bls.gov/news.release/metro.t01.htmhttp s://www.bls.gov/news.release/metro.t01.htm Career Research In-Class Activity ENT229 Name: Date: Over the next 1-2 years… In what industry would you like to work?
- 20. What’s the economic outlook for this industry? Briefly share findings and metrics: Find a specific job posting that would be realistic and enjoyable for you based on your interests, experience and education. Job title: Post the link to the job listing: What’s the economic outlook for this occupation? Briefly share findings and metrics: In what city and state would you like to work? What’s the MSA (Metropolitan Statistical Area) population? What’s the unemployment rate? What can you expect to earn annually in your favorite industry, position and location? [ 2 ] ClInICAl leAderShIp & mAnAgement reVIew
- 21. B U S I N E S S A N D C L I N I C A L o P E R A T I o N S Accountable Care Organizations Laboratory leaders are challenged to embrace and lead upcoming changes. Traditional fee for service healthcare, including Medicare, neither incents nor rewards physicians, hospitals, and other providers for coordinating care. Because of rising healthcare costs and concerns regarding quality, ACOs have been proposed. Dartmouth’s Elliott Fisher has been credited with coining the term “Accountable Care Organizations” in 2006 and the principles of ACOs were included in the Patient Protection and Affordable Care Act (PPACA).1 It is unclear at this time what impact ACOs will have on laboratories across the United States. What is clear is that ACOs are an attempt to pay for value, rather than vol- ume or intensity of services, which is the current practice. The Integrated Healthcare Association (IHA) stated that ACOs are meant to “promote higher quality and more ef- ficient healthcare delivery in the United States.”2
- 22. There are three levels of the proposed ACO Networks3. See Figure 1. An “ACO is a local healthcare organization and a re- lated set of providers…that can be held accountable for the cost and quality of care delivered to a defined population.”4 The ACOs that meet their cost and quality goals can expect some kind of financial reward, while those ACOs that do not meet their goals will likely receive a financial penalty. The ACO needs to be able to plan its budget and resources and to implement seamless, integrated healthcare for its population of patients in different settings, both outpatient and inpatient. Kelly J. Devers, PhD, senior fellow and Robert A. Be- renson, MD, institute fellow at the Urban Institute in their Robert Wood Johnson-sponsored study, concluded that the ACO model is “inherently flawed” and that “the weak fi- nancial incentives in the SSP payment model will not bring together these increasingly independent professionals.”5 The Laboratory Leader’s Dilemma Responding to the Emergence of New Healthcare Delivery Models By James S. Hernandez, MD, MS Due to the changing healthcare landscape, laboratory leaders are best positioned to ensure that their laboratories are effective, while simultaneously striving for efficiency, quality, and cost-effectiveness. This is especially true in the current healthcare environment. Since Accountable Care Organizations (ACOs) are being considered, lab leaders must understand
- 23. the implications and respond appropriately. Figure 1. Level One ACO Network Level Two ACO Network Level Three ACO Network No financial risk for providers Has financial risk for spending that exceeds targets Risk for full or partial capitation Measures basic quality, efficiency, and patient experience Measures quality, efficiency, and patient experience Expanded measures for quality, efficiency, and patient experience Provides some share of savings Provides greater bonus potential for savings Provides additional quality bonuses Volume 25 / ISSue 1 / AprIl 2011 [ 3 ] How do ACOs differ from other attempts to control costs and improve quality? Like HMOs, the providers, not the insur- ers, will be accountable. Ideally, ACOs will be physician led. Kip Sullivan states that, like HMOs, ACOs are account-
- 24. able for cost and will shift the responsibility of cost sharing from insurance companies and Medicare to providers. Kai- ser Permanente is held as an example of an ACO.6 Recently, as part of its transformation efforts, the Col- lege of American Pathologists (CAP) joined the Brookings- Dartmouth ACO Learning Network. The CAP site states that "to help ensure pathologists have a role in structuring new healthcare delivery models, the College has joined the 2010- 2011 Brookings-Dartmouth Accountable Care Organization (ACO) Learning Network.” Furthermore, the CAP site explains that “The Network is headed up by Dartmouth Institute for Health Policy and Clinical Practice's Elliott Fisher, MD, and former CMS Administrator Mark McClellan, MD, PhD, who is now with the Brookings Institution's Engelberg Center for Health Care Reform. Both Drs. Fisher and McClellan are lead- ing experts on ACOs; Dr. Fisher is credited with launching the ACO concept.”7 The CAP website provides numerous examples of healthcare organizations like Kaiser and Inter-
- 25. mountain Healthcare that have been cited as model ACOs. Dr. Elizabeth Hammond, professor of pathology at the University of Utah, outlines the 10 steps that a healthcare organizations can take to form an ACO and several prudent recommendations.8 The principles embraced at Intermoun- tain Healthcare are quite similar to the principles espoused in the Mayo Clinic integrated healthcare system.9 For example, both Intermountain Healthcare and Mayo Clinic employ physicians, so financial incentives are easier to align. Both systems are integrated and their labs are aligned with the strategic plans of the overall healthcare systems, not at cross purposes. Both embrace continuous quality improvements in the laboratories, including the use of Lean principles. Both organizations make use of evidence-based principles, using local data, to make deci- sions in the laboratories to improve quality and safety. Both embrace a “compassionate, accountable culture”10 and both organizations vigorously pursue innovation.
- 26. Efforts to Increase Quality, Improve Efficiency, and Lower Costs Quality process improvement efforts are less novel today compared to five years ago. Many healthcare systems have adopted the principles of Lean, Six Sigma, and Plan-Do- Study-Act (PDSA). The reason for using Lean principles is to eliminate waste within the laboratories and to improve quality and safety. The primary target is improving workflow, for example, by eliminating or greatly diminishing batching and performing [ 4 ] ClInICAl leAderShIp & mAnAgement reVIew tests as they come into the lab, so-called single piece flow. Six Sigma, on the other hand, is a statistical based problem solving and improvement methodology. Six Sigma is used to eliminate variation. An example in the labs is to establish a standardized process to greatly eliminate labeling errors. Six Sigma uses a framework called DMAIC in which the process is to Define, Measure, Analyze, Improve and Control the process, using various quality tools at each stage. Many laboratories have embraced these quality im- provement tools in order to improve efficiency and quality while simultaneously lowering overall costs. Our organi- zation is actively sponsoring a Quality Academy to teach healthcare providers, side by side with systems engineers
- 27. who often have Six Sigma Black Belt credentials, how to set up quality process improvement projects to increase quality and safety, improve efficiency, eliminate waste, and lower overall costs.11 Laboratorians have been trendsetters in our organization, accounting for a large proportion of leaders who have sought advanced training in Lean and Six Sigma. For example, Lean and Six Sigma tools were used to improve turnaround times and the granulocyte and collec- tion process at our institution in the following manner: “This was an overall look at a process that integrated many work units and incorporated the need to understand the work flow from many areas with many needs. One dramatic example from Transfusion Medicine was dealing with the granulocyte request and collection process. This included physicians from primary care and transfusion medicine, residents, the Therapeutic Apheresis Unit, the Component Laboratory and the Transfusion Laboratory. All of these units and groups of people needed to understand each others’ processes and the needs of the whole system. A systems engineer was able to help gather the information and compile it in an understandable manner. The TAT from initiation of the issue of a collected product was reduced from originally 30+ hours to 24 hours for the first product. Subsequent product collection and issue is now standard- ized and much more efficient.”12 Productivity is relatively straightforward to measure. It is a rate of work over time or a similar metric. Productivity commonly applies to clinical practice or to academic pur- suits such as publications or research grants. The science of measuring healthcare efficiency is ad- vancing. In 2005 Hollingsworth13 reviewed 188 published papers on so-called frontier efficiency measurement. He
- 28. concluded that there are applications to both hospitals and other healthcare organizations in assessing efficiency. Frontier efficiency is adapted from finance models for ef- ficient investing and includes measures of inefficiency. For example, in his original research, Zuckerman “uses a stochastic frontier multiproduct cost function to derive hospital-specific measures of inefficiency. The cost func- tion includes direct measures of illness severity, output quality, and patient outcomes to reduce the likelihood that the inefficiency estimates are capturing unmeasured differences in hospital outputs. Models are estimated using data from the AHA Annual Survey, Medicare Hospital Cost Reports, and MEDPAR… We conclude that inefficiency accounts for 13.6 percent of total hospital costs.”14 What Gets Lost in the Equation? Effectiveness Though the levels of ACOs mention “quality, efficiency, and patient experience,” there is no mention of ensuring that the organization as a whole or that individual practitioners are practicing effectively (doing the right thing), or whether the chosen diagnostic and treatment modalities are supported by evidence-based medicine. Furthermore, there is no indi- cation that the pathways chosen in diagnosis and treatment
- 29. are medically useful, efficacious, or cost-effective. In other words, who is tasked to make sure that patients are getting the most effective care? Where are the incentives to align good, effective care with the goals of improving efficiency, cost-effectiveness, and patient satisfaction? Leadership vs. Management Laboratory directors are responsible for the leadership of the laboratory and working with laboratory managers and their staff. Leadership in the labs is about producing needed changes to cope with a rapidly changing environ- ment and setting a strategic direction. It includes determin- ing the effectiveness (doing the right thing) in the labs by identifying the overuse, underuse, or misuse of resources. Laboratory directorship duties cannot be totally abrogated to non-physician managers, but is a shared experience. Leadership is about setting direction, strategy, and priori- ties. It includes mentoring younger colleagues, modeling behavior, and motivating others to move in a direction that
- 30. they may not, on their own, choose to go. In contrast, management of the laboratories is a shared responsibility between the laboratory directors and laboratory administration and management. It addresses efficiency (doing the thing well) and helps produce predictable results by meet- ing measurable goals. Management is about planning and tactics. It includes defining problems clearly, solving complex problems, tracking changes, and controlling the status quo. Leadership is about defining the mission. Management is about fulfilling the mission. Invariably, there is a natural and expected tension be- tween laboratory directors and laboratory management. As management guru John Kotter stated, “management is about coping with complexity…leadership, by contrast, is about coping with change.”15 In contrast to leadership, one can be Volume 25 / ISSue 1 / AprIl 2011 [ 5 ] an excellent manager without motivating or inspiring others
- 31. because “control is central to management…management pro- cesses must be as close to possible to fail-safe and risk-free.”16 Efficiency and productivity are easier to measure com- pared to effectiveness. To some extent, they are more mana- gerial in nature. On the other hand, optimizing effectiveness is a distinctly medical leadership task, in consultation with the laboratory management and the physician staff. Finally, it is important to balance the leadership and management duties with the regulatory and compliance challenges that face pathologists and lab directors. This is particularly true for medical directors of laboratories who are predominantly anatomic pathologists. Some may be ful- filling medical director duties and may not even realize the critical importance of regulatory and compliance issues.17 Conclusion It is incumbent on laboratory directors, due to their medical and scientific training and understanding of both medical processes and outcomes, to work with laboratory manage- ment and physician staff to adequately assess if providers
- 32. are delivering effective care. With the explosion of medical technology, a major driver in escalating costs, lab directors must work with clinical physician staff leaders to assess the effectiveness of the system and of individual providers. The major challenge is for laboratory leaders not to lose sight of striving for medical effectiveness in the zeal to improve efficiency, quality, and productivity. The labo- ratory leader’s dilemma is to respond to external pressures to increase quality while lowering costs (increasing value) and improving efficiency, and simultaneously increasing ef- fectiveness, which is either ignored or assumed to be present across all healthcare systems. Though it is still too early to provide data other than the outcomes of healthcare institutions like Intermountain Healthcare and Kaiser, it is clear that the Patient Protec- tion and Affordable Care Act includes ACOs. For laboratory leaders, this indicates that the concept of paying for value, rather than volume or intensity of services, is in vogue again.
- 33. What does this mean for laboratory leaders and what must laboratorians do to prepare for the coming changes? 1. Learn about Accountable Care Organizations (ACOs). 2. Be open to change. 3. Improve your systems thinking. Think about how your laboratory delivers care in the broader con- text of your healthcare system and how you can assist your entire healthcare team to make your system more efficient and more effective. 4. Champion efforts to make the laboratories more efficient by learning more about Lean, Six Sigma, and other quality process improvement initiatives. 5. Advocate for effectiveness – doing the right thing – by embracing data-driven evidence to improve the practice patterns of your local healthcare system. ◾ References 1. The Patient Protection and Affordable Care Act (PPACA), ac- cessed 1/3/11 at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.
- 34. cgi?dbname=111_cong_public_laws&docid=f:publ148.111.pdf 2. Expert Says Accountable Care Organizations Must Embrace Patient Choice to be Successful, DARKDAILY, accessed 11/25/10 at http://www.darkdaily.com/expert-says-accountable-care- organiza- tions-must-embrace-patient-choice-to-be-successful-1124 3. Ibid. 4. Devers, K. and Berenson, R. Can Accountable Care Organizations Improve the Value of Health Care by Solving the Cost and Quality Quandaries? Accessed 11/25/10 at http://www.urban.org/upload- edpdf/411979_acountable_care_orgs_summary.pdf 5. Ibid. 6. Sullivan, K. The History and Definition of “Accountable Care Organizations.” Accessed 1/3/11 at http://pnhp- california.org/2010/10/the-history-and-definition-of-the- %E2%80%9Caccountable-care-organization%E2%80%9D/ 7. New Economic Realities, CAP website. Accessed on 1/3/11 at http://www.cap.org/apps/docs/membership/transformation/new/ new_economic_realities.html 8. Hammond, E. A Path to Becoming a Model ACO. Accessed on 1/3/11 at http://www.cap.org/apps/docs/membership/transforma- tion/new/aco_model.pdf 9. Mayo Clinic Model of Care. Accessed on 1/3/11 at
- 35. http://www.mayoclinic.org/tradition-heritage/model-care.html 10. Hammond, E. A Path to Becoming a Model ACO. Accessed on 1/3/11 at http://www.cap.org/apps/docs/membership/transforma- tion/new/aco_model.pdf 11. Hernandez, JS and Mustapha, M. Systems Engineers Working with Physician Leaders. Physician Executive Journal, Nov-Dec 2010: 44-48. 12. Ibid. 13. Hollingsworth, B. Non-Parametric and Parametric Applications Measuring Efficiency in Health Care, as cited in Health Care Management Science, Vol. 6, No. 4, 203-218, 2005. 14. Zuckerman, S. Measuring hospital efficiency with frontier cost function. Accessed on 1/3/11 at http://www.sciencedirect.com/sci- ence?_ob=ArticleURL&_udi=B6V8K-45BCTHX- C&_user=130561&_ coverDate=10%2F31%2F1994&_rdoc=1&_fmt=high&_ orig=browse&_origin=browse&_zone=rslt_list_item&_srch=doc -in fo(%23toc%235873%231994%23999869996%23290247%23FLP %23 display%23Volume)&_cdi=5873&_sort=d&_docanchor=&_ct=1 4&_ acct=C000010878&_version=1&_urlVersion=0&_userid=13056 1&md 5=76a5374d7c448caec14c7480ee247589&searchtype=a
- 36. 15. Kotter, John P. What Leaders Really Do. In: Harvard Business Review on Leadership. Boston: Harvard Business School Publishing, 1998: 37. 16. Ibid, page 47. 17. Hernandez JS. Are you responsible for medical director duties in anatomic pathology--and why should you care? Adv Anat Pathol. 2011 Jan; 18(1):75-8. James S. Hernandez, MD, MS, is assistant professor of laboratory medicine and pathology at the College of Medicine, Mayo Clinic. He is also medical director of laboratories and chair of the Division of Laboratory Medicine at Mayo Clinic in Arizona. Dr. Hernandez has a strong inter- est in laboratory leadership, management, lab utilization, quality process improvements, safety, and cost-effectiveness. He can be reached at [email protected] http://frwebgate.access.gpo.gov/cgi- bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ14 8.111.pdf http://frwebgate.access.gpo.gov/cgi- bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ14 8.111.pdf http://www.darkdaily.com/expert-says-accountable-care- organizations-must-embrace-patient-choice-to-be-successful- 1124
- 40. Copyright of Clinical Leadership & Management Review is the property of Clinical Laboratory Management Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Button 11: Button 12: STATEMENT Statement of Glenn M. Hackbarth, J.D. Chairman Medicare Payment Advisory Commission Before the Senate Finance Committee Roundtable on
- 41. Reforming America’s Health Care Delivery System Reforming America’s Health Care Delivery System April 21, 2009 1 Chairman Baucus, Ranking Member Grassley, distinguished Committee members. I am Glenn Hackbarth, chairman of the Medicare Payment Advisory Commission (MedPAC). I appreciate the opportunity to be part of the panel this morning and to share MedPAC’s views on delivery system reform. The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The
- 42. Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare. The Commission's 17 members bring diverse expertise in the financing and delivery of health care services. MedPAC meets publicly to discuss policy issues and formulate its recommendations to the Congress. In the course of these meetings, Commissioners consider the results of staff research, presentations by policy experts, and comments from interested parties. Commission members and staff also seek input on Medicare issues through frequent meetings with individuals interested in the program, including staff from congressional committees and the Centers for Medicare & Medicaid Services (CMS), health care researchers, health care providers, and beneficiary advocates.
- 43. Two reports – issued in March and June each year – are the primary outlet for Commission recommendations. In addition to these reports and others on subjects requested by the Congress, MedPAC advises the Congress through other avenues, including comments on reports and proposed regulations issued by the Secretary of the Department of Health and Human Services, testimony, and briefings for congressional staff. Our health care system today The health care delivery system we see today is not a true system: Care coordination is rare, specialist care is favored over primary care, quality of care is often poor, and costs are high and increasing at an unsustainable rate. Part of the problem is that Medicare’s fee-for-service (FFS) 2 payment systems reward more care, and more complex care, without regard to the value of that care. In addition, Medicare’s payment systems create separate payment “silos” (e.g., inpatient hospitals, physicians, post-acute care providers) and do not
- 44. encourage coordination among providers within a silo or across the silos. We must address those limitations—creating new payment methods that will reward efficient use of our limited resources and encourage the effective integration of care. Medicare has not been the sole cause of the problem, nor should it be the only participant in the solution. Private payer rates and incentives perpetuate system inefficiencies, and the current disconnect among different payers creates mixed signals to providers. This contributes to the perception that one payer is cross-subsidizing other payers and further exacerbates the problem. Private and other public payers will need to change payment systems to bring about the conditions needed to change the broader health care delivery system. But Medicare should not wait for others to act first; it can lead the way to broader delivery system reform. Because this roundtable discussion is intended to spark dialogue on the solutions, I will focus on the recommendations the Commission has made to reform the health care delivery system
- 45. and to strengthen the Medicare program. MedPAC has testified previously before Senate Finance Committee on problems of our health care delivery system and a detailed discussion of these problems is in the attached Appendix. Commission recommendations to increase efficiency and improve quality In previous reports, the Commission has recommended that Medicare adopt tools to surmount barriers to increasing efficiency and improving quality within the current Medicare payment systems. These tools include: • Creating pressure for efficiency through payment updates. Although the update is a somewhat blunt tool for constraining cost growth (updates are the same for all providers in a sector, both those with high costs and those with low costs), constrained updates will create more pressure on those with higher costs. In our March 2009 Report to the Congress, the Commission offers a set of payment update recommendations that exert fiscal pressure on providers to constrain costs. For example, the Commission
- 46. 3 recommends a zero update for home health agencies in 2010, coupled with an acceleration of payment adjustments due to coding practices, totaling a 5.5 percent cut in home health payments for 2010. Another example is the Commission’s recommendation to reduce overpayments to MA plans by setting the MA benchmarks equal to 100 percent of Medicare FFS expenditures. This recommendation is consistent with the Commission’s commitment to retaining high-quality, low-cost private plans in Medicare. • Improving payment accuracy within Medicare payment systems. In our 2005 report on specialty hospitals, the Commission made recommendations to improve the accuracy of DRG payments to account for patient severity. Those recommendations corrected distortions in the payment system that—among other things— contributed to the
- 47. formation of hospitals specializing in the treatment of a limited set of profitable DRGs. In another example, in our June 2008 and March 2009 Reports to the Congress, the Commission recommended increasing fee schedule payments for primary care services furnished by clinicians focused on delivering primary care. This budget-neutral adjustment would redistribute Medicare payments toward those primary care services provided by practitioners—physicians, advanced practice nurses, and physician assistants—whose practices focus on primary care. This recommendation recognizes that a well functioning primary care network is essential to help improve quality and control Medicare spending (MedPAC 2008, MedPAC 2009). • Linking payment to quality. In a series of reports, we have recommended that Medicare change payment system incentives by basing a portion of provider payment on the quality of care they provide and recommended that the Congress establish a quality incentive
- 48. payment policy for physicians, Medicare Advantage plans, dialysis facilities, hospitals, home health agencies, and skilled nursing facilities. In March 2005, the Commission recommended setting standards for providers of diagnostic imaging studies to enhance the quality of care and help control Medicare spending. • Measuring resource use and providing feedback. In our March 2008 and 2005 Reports to the Congress, we recommended that CMS measure physicians’ resource use per episode of 4 care over time and share the results with physicians. Those who used comparatively more resources than their peers could assess their practice styles and modify them as appropriate. • Encouraging use of comparative-effectiveness information and public reporting of provider quality and financial relationships. In our June 2007 Report to the Congress, we found that not enough credible, empirically based information is
- 49. available for health care providers and patients to make informed decisions about alternative services for diagnosing and treating most common clinical conditions. The Commission recommended that the Congress charge an independent entity to sponsor credible research on comparative effectiveness of health care services and disseminate this information to patients, providers, and public and private payers. Second, the Commission recommended public reporting to provide beneficiaries with better information and encourage providers to improve their quality. Third, the Commission has recommended that manufacturers of drugs and medical devices be required to publicly report their financial relationships with physicians to better understand the types of financial associations that may influence patterns of patient care. The need for more fundamental reform The recommendations discussed above would make the current Medicare FFS payment
- 50. systems function better, but they will not fix the problems inherent in those systems for two reasons. First, they cannot overcome the strong incentives inherent in any fee-for-service system to increase volume, thus it will be difficult to make the program sustainable. Second, they cannot switch the focus to the patient rather than the procedure because they cannot directly reward care coordination or joint accountability that cut across current payment system “silos,” such as the physician fee schedule or the inpatient prospective payment system. There is evidence that more fundamental reforms could improve the quality of care and potentially lower costs. For example, patient access to high- quality primary care is essential for a well-functioning health care delivery system. Research suggests that reducing reliance on specialty care may improve the efficiency and quality of health care delivery. States with a 5
- 51. greater proportion of primary care physicians have better health outcomes and higher scores on performance measures (Baicker and Chandra 2004). Moreover, areas with higher rates of specialty care per person are associated with higher spending but not improved access to care, higher quality, better outcomes, or greater patient satisfaction (Fisher et al. 2003, Kravet et al. 2008, Wennberg 2006). Countries with greater dependence on primary care have lower rates of premature deaths and deaths from treatable conditions, even after accounting for differences in demographics and GDP (Starfield and Shi 2002). Changing the balance in the delivery system between primary and specialist care may have high payoffs for Medicare. Evidence points to other potential reforms: • Greater care coordination. Evidence shows that care coordination can improve quality. As we discussed in our June 2006 Report to the Congress, studies show self management programs, access to personal health records, and transition coaches have resulted in
- 52. improved care or better outcomes, such as reduced readmission for patients with chronic conditions. • Reducing preventable readmissions. Savings from preventing readmissions could be considerable. About 18 percent of Medicare hospital admissions result in readmissions within 30 days of discharge, accounting for $15 billion in spending. The Commission found that Medicare spends about $12 billion on potentially preventable readmissions. • Increasing the use of bundled payments. The Medicare Participating Heart Bypass Center demonstration of the 1990s found that bundling hospital DRG payments and inpatient physician payments could increase providers’ efficiency and reduce Medicare’s costs. Most of the participating sites found that, under a bundled payment, hospitals and physicians reduced laboratory, pharmacy, and ICU spending. Spending on consulting physicians and post-discharge care decreased and quality remained high.
- 53. A direction for payment and delivery system reform To increase value for the Medicare program, its beneficiaries, and the taxpayers, we are looking at payment policies that go beyond the current FFS payment system boundaries of scope and time. This new direction would pay for care that spans across provider types and time and would hold providers jointly accountable for the quality of that care and the 6 resources used to provide it. It would create payment systems that reward value and encourage closer provider integration—delivery system reform. For example, if Medicare held physicians and hospitals jointly responsible for outcomes and resource use, new efficiencies—such as programs to avoid readmissions and standardization of operating room supplies—could be pursued. In the longer term, joint responsibility could lead to closer integration and development of a more coordinated health care delivery system. This direction is illustrated in Figure 1. The potential payment
- 54. system changes shown are not the end point for reform and further reforms could move the payment systems away from FFS and toward systems of providers who accept some level of risk, driving delivery system reform. Figure 1. Direction for payment and delivery system reform History provides numerous examples that providers will respond to financial incentives. The advent of the inpatient prospective payment system in 1983 led to shorter inpatient lengths of stay and increasing use of post acute care services. Physician services have increased as payments have been restrained by volume control mechanisms. Finally, a greater proportion of patients in skilled nursing facilities (SNFs) were given therapy, and more of it, in response Recommended tools - Comparative effectiveness - Reporting resource use - Pay for Performance - Individual services “bundled” within a payment
- 55. system - Readmissions - Gain sharing - Creating pressure for efficiency through updates - Price accuracy (e.g. primary care adjustment) - Disclosure of financial relationships Potential system changes Pay across settings and across time For example: - Medical home - Payments “bundled” across existing payment systems - Accountable care organization (e.g. PGP demo) Current FFS payment systems - Physician - Inpatient & outpatient - hospital - LTCH - IRF - Psych
- 56. - SNF - Home health - DME - Lab - Hospice - Dialysis Services + + 7 to the SNF prospective payment system incentives. Financial incentives can also result in structural changes in the health care delivery system. In the 1990s, the rise of HMOs and the prospect of capitation led doctors and hospitals to form physician–hospital organizations whose primary purpose was to allocate capitated payments. Paying differently will motivate providers to interact differently with each other, and—if reforms are carefully designed for joint accountability—to pay more attention to outcomes and costs. To be sure, implementing these changes will not be easy. Changes of this magnitude will undoubtedly be met with opposition from providers and other stakeholders. In addition,
- 57. the administrative component of the proposed payment system changes will require refinement over time. Recommended system changes We discuss three recommendations the Commission has made that might move Medicare in the direction of better coordination and more accountable care: a medical home pilot program, changing payments for hospital readmissions, and bundling payments for services around a hospital admission. Medical home A medical home is a clinical setting that serves as a central resource for a patient’s ongoing care. The Commission considers medical homes to be a promising concept to explore. Accordingly, it recommends that Medicare establish a medical home pilot program for beneficiaries with chronic conditions to assess whether beneficiaries with medical homes receive higher quality, more coordinated care, without incurring higher Medicare spending. Qualifying medical homes could be primary care practices,
- 58. multispeciality practices, or specialty practices that focus on care for certain chronic conditions, such as endocrinology for people with diabetes. Geriatric practices would be ideal candidates for Medicare medical homes. In addition to receiving payments for fee-schedule services, qualifying medical homes would receive monthly, per beneficiary payments that could be used to support infrastructure and activities that promote ongoing comprehensive care management. To be eligible for these monthly payments, medical homes would be required to meet stringent criteria. Medical homes must: 8 furnish primary care (including coordinating appropriate preventive, maintenance, and acute health services); use of a team to conduct care management; use health information technology (IT) for active clinical decision support;
- 59. have a formal quality improvement program; maintain 24-hour patient communication and rapid access; keep up-to-date records of beneficiaries’ advance directives; and maintain a written understanding with each beneficiary designating the provider as a medical home. These stringent criteria are necessary to ensure that the pilot evaluates outcomes of the kind of coordinated, timely, high-quality care that has the highest probability to improve cost, quality, and access. The pilot must assess a true intervention rather than care that is essentially business as usual. In rural areas, the pilot could test the ability for medical homes to provide high-quality, efficient care with somewhat modified structural requirements. Beneficiaries with multiple chronic conditions would be eligible to participate because they are most in need of improved care coordination. About 60 percent of FFS beneficiaries have two or more chronic conditions. Beneficiaries would not incur
- 60. any additional cost sharing for the medical home fees. As a basic principle, medical home practitioners would discuss with beneficiaries the importance of seeking guidance from the medical home before obtaining specialty services. Participating beneficiaries would, however, retain their ability to see specialists and other practitioners of their choice. Under the pilot, Medicare should also provide medical homes with timely data on patients’ Medicare- covered utilization outside the medical home, including services under Part A and Part B and drugs under Part D. A medical home pilot provides an excellent opportunity to implement and test physician pay- for-performance (P4P) with payment incentives based on quality and efficiency. Under the pilot project, the Commission envisions that the P4P incentives would allow for rewards and penalties based on performance. Efficiency measures should be calculated from spending on Part A, Part B, and Part D, and efficiency incentives could take the form of shared savings
- 61. 9 models similar to those under Medicare’s ongoing physician group practice demonstration. Bonuses for efficiency should be available only to medical homes that have first met quality goals and that have a sufficient number of patients to permit reliable spending comparisons. Medical homes that are consistently unable to meet minimum quality requirements would become ineligible to continue participation. It is imperative that the medical home pilot be on a large enough scale to provide statistically reliable results with a relatively short testing cycle. Additionally, the pilot must have clear and explicit results-based thresholds for determining whether it should be expanded into the full Medicare program or discontinued entirely. Focusing on beneficiaries with multiple chronic conditions and medical homes meeting stringent criteria should provide a good test of the medical home concept. Readmissions and bundled payments around a hospitalization
- 62. Evidence suggests there is an enormous opportunity to improve care and address the lack of coordination at hospital discharge. Discharge from the hospital is a very vulnerable time for patients, and in particular for Medicare beneficiaries, who often cope with multiple chronic conditions. Often they are expected to assume a self- management role in recovery with little support or preparation. They may not understand their discharge instructions on what medications to take, know whom to call with questions, or know what signs indicate the need for immediate follow-up care. Often they do not receive timely follow-up care and communication between their hospital providers and post-acute care providers is uneven. These disjointed patterns of care can result in poorer health outcomes for beneficiaries, and in many cases, the need for additional health care services and expenditures. The variation in spending around hospitalization episodes suggests lower spending is possible. There is a 65 percent difference in spending on readmissions between hospitals in
- 63. the top quartile and the average of all hospitals; the top quartile is almost four times higher than the bottom quartile. The spread between high- and low-use hospitals is even larger than spending for post-acute care. These high-spending hospitals often treat the beneficiaries with the costliest care. Greater coordination of care is needed for this population, and changing incentives around their hospital care could be the catalyst. 10 How can Medicare policy change the way care is provided? First, the Commission recommends that the Secretary confidentially report to hospitals and physicians information about readmission rates and resource use around hospitalization episodes (e.g., 30 days post- discharge) for select conditions. This information would allow a given hospital and the physicians who practice in it to compare their risk-adjusted performance relative to other hospitals, physicians, and post-acute care providers. Once equipped with this information,
- 64. providers may consider ways to adjust their practice styles and coordinate care to reduce service use. After two years of confidential disclosure to providers, this information should be publicly available. Information alone, however, will not likely inspire the degree of change needed. Payment incentives are needed. We have two recommendations—one to change payment for readmissions and one to bundle payments across a hospitalization episode. Either policy could be pursued independently, but the Commission views them as complementary. A change in readmissions payment policy could be a critical step in creating an environment of joint accountability among providers that would, in turn, enable more providers to be ready for bundled payment. Readmissions The Commission recommends changing payment to hold providers financially accountable for service use around a hospitalization episode. Specifically, it would reduce payment to
- 65. hospitals with relatively high readmission rates for select conditions. Conditions with high volume and high readmissions rates may be good candidates for selection. Focusing on rates rather than numbers of readmissions serves to penalize hospitals that consistently perform worse than other hospitals, rather than those that treat sicker patients. The Commission recommends that this payment change be made in tandem with a previously recommended change in law (often referred to as gainsharing or shared accountability) to allow hospitals and physicians to share in the savings that result from re- engineering inefficient care processes during the episode of care. Currently, Medicare pays for all admissions based on the patient’s diagnosis regardless of whether it is an initial stay or a readmission for the same or a related condition. This is a 11 concern because we know that some readmissions are avoidable and in fact are a sign of poor
- 66. care or a missed opportunity to better coordinate care. Penalizing high rates of readmissions encourages providers to do the kinds of things that lead to good care, but are not reliably done now. For example, the kinds of strategies that appear to reduce avoidable readmissions include preventing adverse events during the admission, reviewing each patient’s medications at discharge for appropriateness, and communicating more clearly with beneficiaries about their self-care at discharge. In addition, hospitals, working with physicians, can better communicate with providers caring for patients after discharge and help facilitate patients’ follow-up care. Spending on readmissions is considerable. We have found that Medicare spends $15 billion on all-cause readmissions and $12 billion if we exclude certain readmissions (for example, those that were planned or for situations such as unrelated traumatic events occurring after discharge). Of this $12 billion, some is spent on readmissions that were avoidable and some on readmissions that were not. To target policy to avoidable readmissions, Medicare could
- 67. compare hospitals’ rates of potentially preventable readmissions and penalize those with high rates. The savings from this policy would be determined by where the benchmark that defines a high rate is set, the size of the penalty, the number and type of conditions selected, and the responsiveness of providers. The Commission recognizes that hospitals need physician cooperation in making practice changes that lead to a lower readmission rate. Therefore, hospitals should be permitted to financially reward physicians for helping to reduce readmission rates. Sharing in the financial rewards or cost savings associated with re-engineering clinical care in the hospital is called gainsharing or shared accountability. Allowing hospitals this flexibility in aligning incentives could help them make the goal of reducing unnecessary readmissions a joint one between hospitals and physicians. As discussed in a 2005 MedPAC report to the Congress, shared accountability arrangements should be subject to safeguards to minimize the undesirable
- 68. incentives potentially associated with these arrangements. For example, physicians who participate should not be rewarded for increasing referrals, stinting on care, or reducing quality. 12 Bundled payments for care over a hospitalization episode Under bundled payment, Medicare would pay a single provider entity an amount intended to cover the costs of providing the full range of care needed over the hospitalization episode. Because we are concerned about care transitions and creating incentives for coordination at this juncture, the hospitalization episode should include time post-discharge (e.g., 30 days). With the bundle extending across providers, providers would not only be motivated to contain their own costs but also have a financial incentive to better collaborate with their partners to improve their collective performance. Providers involved in the episode could develop new ways to allocate this payment among themselves.
- 69. Ideally, this flexibility gives providers a greater incentive to work together and to be mindful of the impact their service use has on the overall quality of care, the volume of services provided, and the cost of providing each service. In the early 1990s, Medicare conducted a successful demonstration of a combined physician–hospital payment for coronary artery bypass graft admissions, showing that costs per admission could be reduced without lowering quality. The Commission recommends that CMS conduct a voluntary pilot program to test bundled payment for all services around a hospitalization for select conditions. Candidate conditions might be those with high costs and high volumes. This pilot program would be concurrent with information dissemination and a change in payment for high rates of readmissions. Bundled payment raises a wide set of implementation issues. It requires not only that Medicare create a new payment rate for a bundle of services but also that providers decide how they will share the payment and what behavior they will
- 70. reward. A pilot allows CMS to resolve the attendant design and implementation issues, while giving providers who are ready the chance to start receiving a bundled payment. The objective of the pilot should be to determine whether bundled payment for all covered services under Part A and Part B associated with a hospitalization episode (e.g., the stay plus 30 days) improves coordination of care, reduces the incentive for providers to furnish services of low value, improves providers’ efficiency, and reduces Medicare spending while not otherwise adversely affecting the quality of care. The pilot should begin applying payment changes to only a selected set of medical conditions. 13 Conclusion The process of reform should begin as soon as possible; reform will take many years and Medicare’s financial sustainability is deteriorating. That deterioration can be traced in part to the dysfunctional delivery system that the current payment
- 71. systems have helped to create. Those payment systems must be fundamentally reformed, and the recommendations we have made are a first step on that path. They are, however, only a first step; they fall far short of being a “solution” for Medicare’s long-term challenges. MedPAC has begun to consider other options, such as accountable care organizations (ACOs). In addition, MedPAC will consider steps to alter the process by which payment reforms are developed and implemented, with the goals of accelerating that process. I thank the Committee for its attention, and look forward to working with you to reform Medicare’s payment systems and help bring the health care delivery system into the 21st century. 14 APPENDIX The Case For Fundamental Change The Medicare program should provide its beneficiaries with access to appropriate, high
- 72. quality care while spending the money entrusted to it by the taxpayers as carefully as possible. But too often that goal is not being realized, and we see evidence of poor-quality care and spending growth that threatens the program’s fiscal sustainability. Poor quality Many studies show serious quality problems in the American health care system. McGlynn found that participants received about half of the recommended care (McGlynn et al. 2003). Schoen found wide variation across states in hospital admissions for ambulatory-care- sensitive conditions (i.e., admissions that are potentially preventable with improved ambulatory care) (Schoen et al 2006). In Crossing the Quality Chasm, the Institute of Medicine pointed out serious shortcomings in quality of care and the absence of real progress toward restructuring heath care systems to address both quality and cost concerns (IOM 2001). At the same time that Americans are not receiving enough of the recommended care, the care
- 73. they are receiving may not be appropriate. For 30 years, researchers at Dartmouth’s Center for the Evaluative Clinical Sciences have documented the wide variation across the United States in Medicare spending and rates of service use (Figure 1). Most of this variation is not driven by differences in the payment rates across the country but instead by the use of services. Dartmouth finds most of the variation is caused by differing rates of use for supply- sensitive services—that is, services whose use is likely driven by a geographic area’s supply of specialists and technology (Wennberg et al. 2002). Areas with higher ratios of specialty care to primary care physicians also show higher use of services. 15 Figure 1. Total Medicare spending by Hospital Referral Region Source: Dartmouth Atlas of Health Care, 2005 Medicare claims
- 74. data. The higher rates of use are often not associated with better outcomes or quality and instead suggest inefficiencies. In fact, a recent analysis by Davis and Schoen shows at the state level that no relationship exists between health care spending per capita and mortality amenable to medical care, that an inverse relationship exists between spending and rankings on quality of care, and that high correlations exist between spending and both preventable hospitalizations and hospitalizations for ambulatory-care-sensitive conditions (Davis and Schoen 2007). These findings point to inefficient spending patterns and opportunities for improvement. Sustainability concerns This inefficiency costs the federal government many billions of dollars each year, expenditures we can ill afford. The share of the nation’s GDP committed to Medicare is
- 75. projected to grow to unprecedented levels, squeezing other priorities in the federal budget (Figure 2). For example, the Supplementary Medical Insurance Trust Fund (which covers outpatient and physician services, and prescription drugs) is financed automatically with general revenues and beneficiary premiums, but the trustees point out that financing from the $8,560 to $14,360 $7,830 to $8,560 $7,190 to $7,830 $6,640 to $7,190 $5,280 to $6,640 16 federal government’s general fund, which is funded primarily through income taxes, would have to increase sharply to match the expected growth in spending. In addition, expenditures from the Hospital Insurance (HI) trust fund, which funds inpatient stays and other post-acute care, exceeded its annual income from taxes in 2008. In their most recent report, the Medicare trustees project that, under intermediate assumptions, the assets
- 76. of the HI trust fund will be exhausted in 2019. Income from payroll taxes collected in that year would cover 78 percent of projected benefit expenditures. (The recent downturn in the economy is expected to move the HI exhaustion date closer by one to three years in the next Trustees’ Report (BNA 2009).) Figure 2. Medicare faces serious challenges with long-term financing 0% 2% 4% 6% 8% 10% 12% 1966 1976 1986 1996 2006 2016 2026 2036 2046 2056 2066 2076 P er
- 77. ce nt o f G D P Payroll taxes Tax on benefits Premiums General revenue t f State transfers Total expenditures Actual Projected HI deficit Note: GDP (gross domestic product), HI (Hospital Insurance). These projections are based on the trustees’ intermediate set of assumptions. Tax on benefits refers to a portion of income taxes that higher income individuals pay on Social Security benefits that is designated for Medicare. State transfers (often called the Part D “clawback”) refer to payments called for within the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 from the states to Medicare for assuming primary responsibility for
- 78. prescription drug spending. Source: 2008 Annual Report of the Boards of Trustees of the Medicare Trust Funds. 17 Rapid growth in Medicare spending has implications for beneficiaries and taxpayers. Between 2000 and 2007, Medicare beneficiaries faced average annual increases in the Part B premium of nearly 9.8 percent. Meanwhile, monthly Social Security benefits grew by about 4 percent annually over the same period. The average cost of SMI premiums and cost sharing for Part B and Part D absorbs about 26 percent of Social Security benefits. Growth in Medicare premiums and cost sharing will continue to absorb an increasing share of Social Security income. At the same time, Medicare’s lack of a catastrophic cap on cost sharing will continue to represent a financial risk for beneficiaries. Almost 60 percent of beneficiaries
- 79. (or their former employers) now buy supplemental coverage to help offset this risk and Medicare’s cost sharing. Barriers to achieving value in Medicare Many of the barriers that prevent Medicare from improving quality and controlling costs— obtaining better value—stem from the incentives in Medicare’s payment systems. Medicare’s payment systems are primarily fee-for-service (FFS). That is, Medicare pays for each service delivered to a beneficiary by a provider meeting the conditions of participation for the program. FFS payment systems reward providers who increase the volume of services they provide regardless of the benefit of the service. As discussed earlier, the volume of services per beneficiary varies widely across the country, but areas with higher volume do not have better outcomes. FFS systems are not designed to reward higher quality; payments are not increased if quality improves and in some cases may increase in response to low-quality care. For example, some hospital readmissions may be a result of poor-quality care and currently
- 80. those readmissions are fully paid for by Medicare. While this testimony focuses on changes to Medicare FFS payment systems that would encourage delivery system reform, the payment system for Medicare Advantage (MA) plans also needs reform, as we have previously reported. In aggregate, the MA program continues to be more costly than the traditional program. Plan bids for the traditional Medicare benefit package average 102 percent of FFS in 2009, compared with 101 percent of FFS in 2008. In 2009, MA payments per enrollee are projected to be 114 percent of comparable FFS spending for 2009, compared with 113 percent in 2008. Many MA plans have not changed 18 the way care is delivered and often function much like the Medicare FFS program. High MA payments provide a signal to plans that the Medicare program is willing to pay more for the same services in MA than it does in FFS. Similarly, these higher payments signal to
- 81. beneficiaries that they should join MA plans because they offer richer benefits, albeit financed by taxpayer dollars. This is inconsistent with MedPAC’s position supporting financial neutrality between FFS and MA. To encourage efficiency across the Medicare program, Medicare needs to exert comparable and consistent financial pressure on both the FFS and MA programs, coupled with meaningful quality measurement and pay-for- performance (P4P) programs, to maximize the value it receives for the dollars it spends. MedPAC has identified five specific problems that make it difficult for Medicare to achieve its goals: lack of fiscal pressure, price distortion, lack of accountability, lack of care coordination, and lack of information. These are discussed below. Lack of fiscal pressure. Medicare payment policies ought to exert fiscal pressure on providers. In a fully competitive market, this happens automatically through the “invisible hand” of competition. Under Medicare’s administered price systems, however, the Congress
- 82. must exert this pressure by limiting updates to Medicare rates— or even reducing base rates in some instances (e.g., home health). MedPAC’s research shows that provider costs are not immutable; they vary according to how much pressure is applied on rates. Providers under significant cost pressure have lower costs than those under less pressure. Moreover, MedPAC research demonstrates that providers can provide high- quality care even while maintaining much lower costs. Our analysis shows that in 2007 hospitals under low financial pressure in the prior years had higher standardized costs per discharge ($6,400) than hospitals under high financial pressure ($5,800). Over time, aggregate hospital cost growth has moved in parallel with margins on private-payer patients. Due to managed care restraining private-payer payment rates in the 1990s, hospitals’ rate of cost growth in that period was below input price inflation. However, from 2001 through 2007, after profits from private payers increased, hospitals’ rate of cost growth was higher than the rate of increase in the market basket
- 83. of input prices. All things being equal, increases in providers’ costs will result in lower Medicare margins. We also 19 found that hospitals with the highest private payments and most robust non-Medicare sources of revenues have lower Medicare margins (–11.7 percent) than hospitals under greater fiscal pressure (4.2 percent). Price distortion. Within Medicare’s payment systems, the payment rates for individual products and services may not be accurate. Inaccurate payment rates in Medicare’s payment systems can lead to unduly disadvantaging some providers and unintentionally rewarding others. For example, under the physician fee schedule, fees are relatively low for primary care and may be too high for specialty care and procedures. This payment system bias has signaled to physicians that they will be more generously paid for procedures and specialty care, and signals providers to generate more volume. In turn,
- 84. these signals could influence the supply of providers, resulting in oversupply of specialized services and inadequate numbers of primary care providers. In fact, the share of U.S. medical school graduates entering primary care residency programs has declined in the last decade, and internal medicine residents are increasingly choosing to sub-specialize rather than practice as generalists. Lack of accountability. Providers may provide quality care to uphold professional standards and to have satisfied patients, but Medicare does not hold them accountable for the quality of care they provide. Moreover, providers are not accountable for the full spectrum of care a beneficiary may use, even when they make the referrals that dictate resource use. For example, physicians ordering tests or hospital discharge planners recommending post-acute care do not have to consider the quality outcomes or the financial implications of the care that other providers may furnish. This fragmentation of care puts quality of care and
- 85. efficiency at risk. Lack of care coordination. Growing out of the lack of accountability, there is no incentive for providers to coordinate care. Each provider may treat one aspect of a patient’s care without regard to what other providers are doing. There is a focus on procedures and services rather than on the beneficiary’s total needs. This becomes a particular problem for beneficiaries with several chronic conditions and for those transitioning between care providers, such as at 20 hospital discharge. Poorly coordinated care may result in patient confusion, over-treatment, duplicative service use, higher spending, and lower quality of care. Lack of information and the tools to use it. Medicare and its providers lack the information and tools needed to improve quality and use program resources efficiently. For example, Medicare lacks quality data from many settings of care, does not have timely cost or market data to set
- 86. accurate prices, and does not generally provide feedback on resource use or quality scores to providers. Individually, providers may have clinical data, but they may not have that data in electronic form, leaving them without an efficient means to process it or an ability to act on it. Crucial information on clinical effectiveness and standards of care either may not exist or may not have wide acceptance. In this environment, it is difficult to determine what health care treatments and procedures are needed, and thus what resource use is appropriate, particularly for Medicare patients, many of whom have multiple comorbidities. In addition, beneficiaries are now being called on to make complex choices among delivery systems, drug plans, and providers. But information for beneficiaries that could help them choose higher quality providers and improve their satisfaction is just beginning to become available. 21 References Baicker, K., and A. Chandra. 2004. Medicare spending, the
- 87. physician workforce, and beneficiaries’ quality of care. Health Affairs (April): 184–196. BNA. U.S. Health Care Spending Reached $2.4 Trillion in 2008, CMS Report Says. BNA (February 24, 2009). Davis, K., and C. Schoen, 2007. State health system performance and state health reform. Health Affairs Web Exclusive (September 18): w664–w666. Fisher, E., D. Wennberg, T. Stukel, et al. 2003a. The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care. Annals of Internal Medicine 138, no. 4 (February 18): 273–287. Fisher, E., D. Wennberg, T. Stukel, et al. 2003b. The implications of regional variations in Medicare spending. Part 2: Health outcomes and satisfaction with care. Annals of Internal Medicine 138, no. 4 (February 18): 288–298. Institute of Medicine. 2001a. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Kravet, S., Andrew D. Shore, Redonda Miller, et al. 2008. Health care utilization and the proportion of primary care physicians. American Journal of Medicine 121, no. 2: 142–148. Medicare Payment Advisory Commission. 2005. Issues in a Modernized Medicare Program. Washington, DC: MedPAC.