医改方案有序推进的前提:解决问题求得突破

明确了解决问题求得突破与医改方案有序推进之间的关系,认为:"总额预算+按服务单元付费"组合支付为完善四大服务体系,尤其是医疗服务、药品供应保障、医疗保障三大服务体系提供了基础,也为近期医改五项重点改革,尤其是公立医院改革试点、初步建立国家基本药物制度提供了前提,同时提供了一些关键改革措施落实的必要条件。由此,建立基本医疗卫生制度的目标达成将变得可望又可及。     

The introduction of electronic medical records in France: More progress during the second attempt

To support care coordination, a national electronic medical record (DMP), has been created by law in 2004. Because of technical difficulties and delays during implementation, the project was entrusted to a dedicated technical agency in 2009. But 3 years later, only 160,000 DMPs had been opened contrary to the several million expected. Physicians criticized the technical and administrative burden, but the main factors highlighted were resistance to sharing information with patients and with other professionals. Failing to cross the critical threshold of users that gives value to the system, the project failed. After this first attempt, the project was entrusted by law to the national health insurance fund in 2016. The new policy was addressed to patients, professionals and software companies. The policy has allowed patients to independently access and modify their DMP data already in possession of the national public medical insurance, and has introduced financial incentives for physicians opening a DMP. As a result the deployment of DMPs has accelerated substantially: 350,000 new DMPs were opened in nine pilot departments within a year. If scaled-up to the entire country, this number would correspond to 4 million DMPs.     

New pathways for primary care: an update on primary care programs from the innovation center at CMS

Those in practice find that the fee-for-service system does not adequately value the contributions made by primary care. The Center for Medicare and Medicaid Innovation (Innovation Center) was created by the Affordable Care Act to test new models of health care delivery to improve the quality of care while lowering costs. All programs coming out of the Innovation Center are tests of new payment and service delivery models. By changing both payment and delivery models and moving to a payment model that rewards physicians for quality of care instead of volume of care, we may be able to achieve the kind of health care patients want to receive and primary care physicians want to provide.     

The March to Accountable Care Organizations—How Will Rural Fare?

Purpose: This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). Methods: ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion. Findings: Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served. Conclusions: Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural‐relevant ACO‐performance measures and provide necessary technical assistance to rural providers and organizations.     

The Role of HIPAA Omnibus Rules in Reducing the Frequency of Medical Data Breaches: Insights From an Empirical Study

Policy Points:

• Frequent data breaches in the US health care system undermine the privacy of millions of patients every year—a large number of which happen among business associates of the health care providers that continue to gain unprecedented access to patients’ data as the US health care system becomes digitally integrated.
• Implementation of the HIPAA Omnibus Rules in 2013 has led to a significant decrease in the number of privacy breach incidents among business associates.

Context

Frequent data breaches in the US health care system undermine the privacy of millions of patients every year. A large number of such breaches happens among business associates of the health care providers that continue to gain unprecedented access to patients’ data as the US health care system becomes digitally integrated. The Omnibus Rules of the Health Insurance Portability and Accountability Act (HIPAA), which were enacted in 2013, significantly increased the regulatory oversight and privacy protection requirements of business associates. The objective of this study is to empirically examine the effects of this shift in policy on the frequency of medical privacy breaches among business associates in the US health care system. The findings of this research shed light on how regulatory efforts can protect patients’ privacy.

Methods

Using publicly available data on breach incidents between October 2009 and August 2017 as reported by the Office for Civil Rights (OCR), we conducted an interrupted time‐series analysis and a difference‐in‐differences analysis to examine the immediate and long‐term effects of implementation of HIPAA omnibus rules on the frequency of medical privacy breaches.

Findings

We show that implementation of the omnibus rules led to a significant reduction in the number of breaches among business associates and prevented 180 privacy breaches from happening, which could have affected nearly 18 million Americans.

Conclusions

Implementation of HIPAA omnibus rules may have been a successful federal policy in enhancing privacy protection efforts and reducing the number of breach incidents in the US health care system.     

The electronic medical record and Patient-centered care

Background:

One goal in EMR development should be to facilitate a patient-centered clinical encounter. Much prior EMR development has focused on capturing objective data, such as laboratory values and medication lists. Less attention has been devoted to the more complex task of capturing and analyzing data that incorporates the patient’s concerns and preferences.

Methods:

A literature search supplemented the author’s own various experiences with one EMR (that used nationally by the Department of Veterans Affairs) from his various perspectives of a physician, an educator, and a Chief of Staff. This data was used to identify both opportunities and obstacles to promoting patient-centered care in an integrated care setting that relies heavily on an EMR. Qualitative analysis and suggestions are offered for how the EMR can individualize patient care, in support of a patient-centered approach.

Result:

Three promising target areas in efforts to develop a patient-centered EMR are: elicitation of the chief complaint, conduct of health screening activities, and evaluation of health literacy. A range of strategies were identified, some of which may require information technology development, such as to facilitate patient direct entry of data into their own EMR.

Conclusion:

EMR design can facilitate a more patient-centered clinical encounter. Beyond the benefits to the individual patient, patient-centric modifications to the EMR architecture may also facilitate quality improvement and research activities on patient centered care. In light of the widespread current discussions of a movement toward Accountable Care Organizations that use EMR, it will be especially important to ensure that the resulting care systems maintain a focus on the patient and not just on the system of care.     

基本卫生保健制度的可行性及实现方式研究

我国建立基本卫生保健制度,已经具备了政治、经济、社会和工作基础。作者对基本卫生保健制度的覆盖对象、筹资方式、服务内容、支付方式及服务提供方式进行了系统研究,提出了自己的观点。     

美国退伍军人医疗服务系统改革综述与经验分析

20世纪90年代中后期美国最大的公立医疗体系——退伍军人医疗服务系统进行了全面的改革,并在临床服务、患者满意度、运行效率和费用控制等方面迅速达到行业领先水平。通过对文献的综述和分析,本文认为美国退伍军人医疗服务系统改革的成功有两方面原因：宏观方面,组织结构的区域性整合与按人头支付的方式相结合,产生了加强预防保健和提升医疗质量的激励机制;微观方面,以绩效监测为手段改革管理机制．应用了适应临床需求的信息技术系统,服务重点从专科住院治疗快速转为初级保健。文章还讨论了其对我国公立医院改革的启示：公立医院改革的核心是建立责权统一的管理结构,而非产权变革;进一步整合的组织结构与按人头支付的方式相结合,可能创造出维护健康的激励机制;在把握宏观改革方向的基础上,科学的绩效管理方法、信息化技术和初级保健能够为医院发展和医疗卫生服务体系的快速转型发挥巨大的推动作用一     

Health economic evaluation of disease management programs

Disease management has become an important element in the improvement of care for persons with chronic illnesses and has become embedded in the health political discussion over recent years. Quite different approaches have been introduced in different countries throughout the world. Accredited disease management programs (DMPs) have been part of the risk structure compensation scheme of the German statutory health insurance since 1 January 2003. This is seen as the first step towards morbidity orientation in the risk structure compensation. DMPs must be evaluated according to German Social Law, especially as to whether the objectives of the programs and the criteria for inclusion of the patients have been met and the quality of care for the patients has been insured. The criteria for evaluation are threefold: medical issues, economic issues, and patients subjective quality of life. As an immense quantity of data can be expected, the evaluation of the German DMPs is a huge logistical challenge. The quality of the data has been subjected to only little analysis. The present study focuses on the perspective of the health insurance funds as information about indirect costs is not covered. We discuss the methods of evaluation.