美国责任保健组织的发展及启示

为提高卫生服务的质量和效率,关国在可支付保健法案框架下探索建立责任保健组织。本文综述了美国在建立责任保健组织过程中,卫生服务体系的整合形式、支付方式改革等主要做法,在保证医疗服务的连续性、实现资源和信息共享、促使供方主动参与、加强对医生管制等方面积累了经验,但发展责任保健组织也面临一些挑战,在机构规模、支付方式改革的全面推进、潜在垄断、患者归属和信息共享等方面存在一定问题。最后提出,在我国卫生服务体系整合的过程中,要使医疗服务机构成为整合主体和核心,建立相应的激励机制,平衡费用、质量和效率之间的关系,防止出现供方垄断,以及建立完善的信息系统等。     

实行母子保健保偿责任制

<正> 我省遵化县于1986年5月在全县推行了母子保健保偿责任制(下称“保偿制”)。到1987年6月底,全县孕妇入保率达85.04%;0～7岁儿童入保率达84.8%。一、建立组织为了保证“保偿制”的推行,县成立了保偿制领导小组,由主管卫生工作的副县长任组长,卫生局长任副组长,县妇幼保健所所长、防疫站站长、卫生局业务股股长为小组成员,负责全县“保偿制”工作的领导及管理。各乡也相应地建立了“保偿制”领导小组,主管卫生工作的副乡长任组长,卫生院院长任副组长,村委会主任、     

美国保健食品原料及食品原料审批法规介绍

随着中国保健食品原料行业的迅速发展,中国和美国之间的保健食品原料和食品原料市场之间关系日趋紧密。中国企业了解向美国出口产品和原料的程序是必要的。为比较和了解美国公民原料审批状况,作者将对美国现行的保健食品原料及食品原料进口政策做一个综述,并给出建议。     

实行母子保健保偿责任制的作法

<正> 现将馆陶县实行母子保健保偿制的具体作法介绍如下: 一、健全组织,明确职责 (一)县级建立以县委、县政府主管卫生的副书记、副县长为首的由民政、财政、卫生、计生委、妇联、工会、宣传部等组成的母子保健保偿协调委员会.负责组织领导、部署,检查保偿制的贯彻执行情况,协调解决有关的重要工作问题.还建立了母子保健保偿技术鉴定指导委员会.由县卫生     

黄山区推行保健保偿责任制的体会

黄山区于1991年首先确定3个乡镇为推行保健保偿责任制试点，然后在总结经验的基础上逐步推广。目前全区有17个乡镇推行不同形式的保健保偿制，覆盖率89．47％，使孕产妇和儿童保健两个系统管理工作取得较好的成效。1基本做法1．l组织领导成立以卫生局长为组长，保健、防疫等单位组成的防保领导组，负责制定工作计划，技术指导，组织检查考核。各乡镇和村成立相应的组织，从事有关的工作。1．2宣传动员利用广播、电视、宣传栏、逢会宣传等多种形式宣传保偿制的意义和妇幼卫生知识。发放宣传资料2万多份，发动群众，参加保健保偿。互．3加强培…     

美国的保健时尚

美国是一个消费水平较高的国家。国民十分注重追求保健时尚,把防病治病渗透在日常生活调理中。 厨房代替药房 大多数美国人对膳食与疾病的关系有较深的了解。60％的人以改变饮食习惯来预防心脏病、高血压、高胆固醇及肥胖。50％多的人认为只要饮食适当,就能避免或减少可怕的癌症。44％的人认为     

美国灾害医学救援组织体系建设的介绍

为应对日益增加的灾害事件,美国建立国家紧急事件处理系统（NIMS）,联邦紧急事务管理署（FEMA）是NIMS的主要核心部门,统一管理全国的防灾救灾工作,负责平战时紧急动员、民防、救灾等政策和计划的制定。行使灾害医学救援的职能部门是国家灾害医学系统（NDMS）,其指导思想是在国内发生重大灾害事件或对外发生常规战争时,对大批伤员进行救治。美国灾害医学救援体系具有以下特点：统一的防灾救援领导机构,“军民一体化”救援模式,十分注重培训和宣传教育。     

美国的流动保健

流动保健是指非住院诊疗的保健机构,如家庭保健和诊所保健形式等。医生诊所的60%是个人经营的单科门诊,40%为集体开业的多科门诊。出诊多数由家庭     

发展中国家的保健组织

保健组织是一种提供保健服务的新方式，它将分担风险（保险）和提供保健服务相结合。这种组织能降低成本的潜力引起美国和其他国家的极大兴趣，也使人们针对这种组织是否适用於其他国家提出了各种问题。本文将对一些发展中国家与美国的保健组织发展与现状做一个介绍。     

推行保健保偿责任制发展妇幼卫生事业

黑河市爱辉区妇幼保健院现有30张床,58名卫生技术人员和9名行政后勤人员,是集保健、医疗、科研为一体的医疗保健机构。自1989年开始,根据黑龙江省卫生厅下发的孕产妇、儿童保健保偿合同制方案和管理办法的有关规定,在全市范围内,开展了孕产妇保健保偿责任制和保健基金制。1996年又根据省卫生厅关于保健保偿责任制有关文件要求,重新修订了方案,区政府发文,在市区内和部分乡镇开展了孕产妇和儿童保健保偿责任制。     

Accountable Care Organizations in the Era of Healthcare Reform

Under the Patient Protection and Affordable Care Act (PPACA) of 2010, Medicare providers, including physician groups and hospitals, will soon have the option to form accountable care organizations (ACOs) to improve quality and efficiency. ACO participants may share financial gains generated from improved clinical and economic performance, provided that quality goals and patient safeguards are met. Through future regulations, the Centers for Medicare & Medicaid Services (CMS) must implement the ACO option no later than January 1, 2012. In this interview, Dr Mark B. McClellan, former CMS Administrator and US Food and Drug Administration Commissioner, discusses the extraordinary implications of the new ACO option for improving patient care and reducing unnecessary costs.Kip Piper, MA, FACHE: You and your colleagues were influential in developing the ACO concept1 and successfully persuading Congress to make ACOs an option in Medicare. Are you surprised by the tremendous interest in ACOs since enactment of the PPACA this year?Mark B. McClellan, MD, PhD: There has been a real expansion of interest in ACOs recently, and some of that is not surprising. The key ideas behind accountable care have been around for a while. CMS has implemented some Medicare demonstration programs previously that potentially use ACO concepts, and a number of private payers and providers have been working on ACO implementation as well. I have been a bit surprised by the breadth of interest. It is a reflection of how seriously providers and payers are taking the healthcare reform law.However, unlike many of the other provisions on payment reform, ACOs will be a real part of Medicare as of 2012, if not earlier; not a pilot, not a demo, but a part of the Medicare program. That may be contributing to the interest too. And finally, there is growing interest in making sure that payment policies fit together to add up to getting better value, getting higher quality, and avoiding unnecessary costs. That''s contributing to the interest in ACOs. It is a confluence of factors, and in retrospect I should not be so surprised by the intense interest in the ACO model.Piper: What are some of the factors critical to successfully implementing an ACO?McClellan: One is a critical mass of providers who are willing and able to meaningfully take accountability for the well-being of a population of patients. This includes a primary care network and other types of healthcare providers, maybe even some providers who are involved in things that are not traditionally thought of as healthcare, such as wellness programs and population health management. But the key thing is that there is a critical mass of providers who are willing to work together and are able to take meaningful steps to get to better health for those beneficiaries.Second, there also is a need for a critical mass of payers. There needs to be enough reform in the way payments work so that steps that traditionally do not make much financial sense—such as promoting better coordination of care, taking steps to reduce complications and readmissions, and exchanging information effectively—make more financial sense. And that takes enough of the payer community to get behind the effort as well.Having both providers and payers simultaneously jump together is a challenge, but there is certainly a growing number of examples of ways to do it successfully. In the end, the success of ACOs is going to depend on actually reforming care so that costs are lower and results are better. It''s not just a matter of getting the critical mass (of providers and payers), but actually having meaningful steps that can be taken. These steps can take a little time, and certainly some effort, to reform the way healthcare works, which requires a commitment of time, effort, and expertise to meaningfully redesign care.Piper: How does the ACO model fit in context with other major reforms, most notably bundled payment, global and episode-based payment reforms, and the medical home model?McClellan: There is a tendency now to look at what is in the healthcare reform legislation and what is being tried in the private sector and states around the country as basically throwing a lot of spaghetti against the wall and seeing what sticks. That is the wrong way to look at these reforms. They all have a common goal of improving care delivery, making it better so that patients are healthier, and making it more efficient so that costs are lower. The best strategy for an organization is to view these as part of an overall approach to getting that result. So, for example, it can actually be easier to implement an ACO successfully by pairing it with a medical home reform.We are seeing many examples of this around the country, where the providers get the support they need for coordinating care and spending more time on patient management by the upfront investment needed to support a meaningful medical home. Payers get some accountability that, by taking these steps (or as they take these steps upfront to support reforms and care delivery), they are going to be able to see what the ultimate consequences are for health and for costs on the back end. That is what an ACO provides. So these reforms can truly reinforce each other. The best way to approach payment reform is as pieces that add up to a more comprehensive and effective whole.Piper: Long-term, which form of payment do you expect will work most effectively with the ACO model—shared fee-for-service savings, partial capitation, or some other form of global payment?McClellan: What we have seen in some early adopters is movement toward having less payment depend on fee for service. But that is not necessarily going to be the outcome. I can imagine some longer-term arrangements where ACOs are operating at a regional level or across a diverse range of providers, where fee-for-service reimbursement may remain a substantial part of payment. The main thing is that ACOs involve setting up a different kind of tracking system for payments than you get with fee for service.In the most basic form of ACOs, with shared savings, in addition to tracking the volume and intensity of services for traditional fee-for-service payments, the organization and its payers will also track some meaningful results for the population of patients being served and per-capita spending. If there are any savings compared with fee-for-service costs, those provide an additional source of reimbursement for the providers.As people get more used to thinking about things that they can do to improve care and to work on improving those patient-focused performance measures rather than just the fee-for-service billing, you can imagine more weight going to this patient-focused payment approach, and it can be gradual. In some examples, it may start out with shared savings. Then, as the providers get more used to working together in this kind of explicit goal-oriented way, as they identify some further steps that they can take together to improve performance, and as they get more comfortable with an explicit patient-level focus, you can imagine putting more weight on the ACO payment model as opposed to fee for service.So maybe reducing the fee-for-service payment by 20% across the board or for primary care services and putting that money into a partial capitation fund would enable the organization to do more to reform care than it can with the resources from shared savings alone. Different organizations may come out in various places. The whole point is to try to support incremental steps that are not too disruptive in the short-term, but that over time could lead to more fundamental improvements and care.Piper: A few skeptics question the readiness of provider organizations in areas such as governance, physician relationships, coordination, health information technology (HIT), and performance measurement. How do you respond?McClellan: Yes, this is hard, especially in the status quo, where it is very difficult for many healthcare providers and provider organizations. Their payment rates are being squeezed. They are facing new reimbursement and regulatory pressures because of rising healthcare costs. Unfortunately, I do not see the status quo getting better. So although this is a real challenge, there are some unique opportunities to support the move toward a different kind of payment, in which providers get better support for delivering better care, not just more squeezes. It makes now a really good time to consider moving forward on addressing these very hard challenges.For example, there is the federal HIT initiative, with Medicare and Medicaid incentive payments for adoption of electronic health record (EHR) systems and meaningful use of EHRs. The objectives of the meaningful use standards are tied directly to improving patient care. This sounds a lot like the goal of accountable care. There are some payments now and over the next few years in Medicare for physicians and other healthcare providers for reporting on performance. That is easier to do if you have an information system in place and if you are actually developing and using information systems to improve care.CMS now has 2 tracks for performance reporting. One is the traditional “fill out another claim form” approach, which is burdensome on providers and does not help improve quality. The other is to submit information from systems used to improve care at the patient level as a registry-based submission to CMS. An increasing number of provider organizations are doing that.There are also other opportunities in terms of medical homes and other payment reforms that can collectively add up to a significant amount of support for addressing things such as governance, effective information technology (IT) use, and improving physician relationships and coordination. But those opportunities are not going to be around forever. I think the next few years are probably the best time to take advantage of all of this support for building up systems that help providers do what they want to do, which is get better results for their patients at a lower cost.Piper: ACOs have been discussed mostly in terms of hospitals and physicians. Does the ACO model hold promise for other combinations of healthcare providers?McClellan: Yes, it does. It is essential to have a network of primary care physicians within an ACO. But there are certainly a lot of opportunities to expand broadly beyond specialist hospitals and other types of traditional healthcare providers. For example, we have heard from a number of communities that already have public health initiatives in place. They want to expand these initiatives to use wellness programs and school-based programs to support ACO goals.State Medicaid programs are finding that if they can expand the support from ACOs and Medicaid to areas like community-based mental health services, they can document some significant reductions in medical costs related to mental illnesses. There are issues that could be addressed through support of care in the community but that are not part of traditional healthcare delivery. I think ACOs actually make it easier to move toward less-traditional forms of delivering care and toward preventing complications and keeping people well. That''s because all these steps in the absence of an ACO run the risk of payer concerns that they may just lead to higher costs and more expenditures. Therefore, some reluctance. With the accountability of the ACO model, it becomes easier to bring in other types of providers, other types of services that may not even be traditional healthcare to get the better results and lower costs.Piper: The Engelberg Center for Health Care Reform, at the Brookings Institution, provides practical solutions to achieve high-quality, innovative, affordable healthcare. What else is the Engelberg Center working on?McClellan: Well, this is sort of high noon for healthcare reform implementation. A lot of people think that the big issues are not coming until 2014, but implementation of reform is under way now. And so we are not only trying to help with effective implementation around accountable care, quality and value, and healthcare payments, but also on other issues, such as evaluating other types of payment reform and other things that may not be viewed as within the traditional reform but probably should be.For example, we are doing work with a network of health plans and EHR systems on developing a better surveillance capability in this country for monitoring the safety of medical products. We have got an IT infrastructure now, incomplete as it is, that could provide much more timely information on potential safety problems. So we need to take steps to use that.Of course, healthcare reform is never done. So we are following up on some of our earlier work on bending the curve in healthcare, with ideas that may be considered in the next round of healthcare reform. The President has a commission on deficit reduction that will report later this year. In 2011, unquestionably there will be more healthcare legislation related to implementation of the new law, funding it, and perhaps building on it. So we are trying to provide some useful guidance for all of that too.What a lot of these projects have in common is a recognition that private sector leadership is needed for real reform in healthcare, and for making our public-private system work better, but that this needs to be aligned with effective federal, state, and local government policies to support shared goals. And one of the things we have tried to do here at the Engelberg Center—as a neutral, expert-oriented think tank—is to help bring together these different perspectives in practical ways to make progress on the big challenges of reform in all of these areas.     

Achieving Population Health in Accountable Care Organizations

Although “population health” is one of the Institute for Healthcare Improvement’s Triple Aim goals, its relationship to accountable care organizations (ACOs) remains ill-defined and lacks clarity as to how the clinical delivery system intersects with the public health system.Although defining population health as “panel” management seems to be the default definition, we called for a broader “community health” definition that could improve relationships between clinical delivery and public health systems and health outcomes for communities.We discussed this broader definition and offered recommendations for linking ACOs with the public health system toward improving health for patients and their communities.WITH THE PASSAGE OF THE Affordable Care Act (ACA),1 the United States has turned its attention to improving the quality of health care while simultaneously decreasing cost. As we move toward alternative and global payment arrangements, the need to understand the epidemiology of the patient population will become imperative. Keeping this population healthy will require enhancing our capacity to assess, monitor, and prioritize lifestyle risk factors that unduly impact individual patient health outcomes. This is especially true, given that only 10% of health outcomes are a result of the medical care system, whereas from 50% to 60% are because of health behaviors.2,3 To change health behaviors, it will be necessary to engage in activities that reach beyond the clinical setting and incorporate community and public health systems.4The Institute for Healthcare Improvement (IHI), a leading not-for-profit organization dedicated to using quality improvement strategies to achieve safe and effective health care, has developed the Triple Aim initiative5 as a rubric for health care transformation. The three linked goals of the Triple Aim include improving the experience of care, improving the health of populations, and reducing per capita costs of health care.6 However, although two of the three aims–experience of care and cost reduction–are self-explanatory, there is little consensus about how to define population health. Words like “panel management,” “population medicine,” and “population health” are being used interchangeably. Berwick et al.6 describe the care of a population of patients as the responsibility of the health care system and use broad-based community health indicators as evidence of improvement. Other recent publications have attempted to describe population health from the hospital,7–10 primary care,11 and community health center perspectives.12 The “clinical view” identifies the population as those “enrolled” in the care of a specific provider, provider or hospital system, insurer, or health care delivery network (i.e., panel population).7 Alternatively, from the public health perspective,8 population is defined by the geography of a community (i.e., community population) or the membership in a category of persons that share specific attributes (e.g., populations of elderly, minority population). In either case, the context of a community and the existing social determinants of health, ranging from poverty to housing, are known to have substantial impact on individual health outcomes. Thus, ensuring the health of a population is highly dependent on addressing these social determinants and requires collaborative relationships with community institutions outside the health care setting.13,14Two key concepts that will greatly influence the definition and actualization of population health in the post-ACA era include the accountable care organization (ACO)15 and the patient-centered medical home (PCMH).16 The ACO represents an integrated strategy at the delivery system level to respond to payment reform.15 These integrated systems of care are poised to manage a population of patients under a global payment model. The PCMH is focused on transforming primary care to better deliver “patient-centered” care and to address the whole patient, including their health and social needs.17,18 Both models will need to identify, monitor, and manage their “population” of patients. However, their ability to extend their definition of population health to encompass the entire community will depend on resources, market share, and the strength and capacity of collaborating community and public health organizations. As integrated delivery systems are asked to do more than focus on their own patients, they will require additional resources. These may come from a realignment of existing programs (community benefits), a return on investment from effective preventive care, or collaborative relationships with existing community and public health organizations.In this article, we discuss two major points regarding ACOs and their approach to population health. First, ACOs should be committed to serving the health of the people in the communities from which their population is drawn, and not just the population of patients enrolled in their care to achieve the population health goal. Second, to achieve this expanded definition of population health, ACOs will need to engage in collaborative efforts with community agencies and the public health system. We describe a “community” definition of population health to be used in lieu of the “panel” definition and then outline the resources needed and strategies for collaboration. Finally, we offer recommendations to assist ACOs in realizing their population health goal.     

Behavioral Health and Health Care Reform Models: Patient-Centered Medical Home, Health Home, and Accountable Care Organization

Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient-Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools—accountability measures and payment designs—to improve access to and quality of care for patients with behavioral health needs.     

The Economics of Medicare Accountable Care Organizations

Background

Accountable care organizations (ACOs) have been created to improve patient care, enhance population health, and reduce costs. Medicare in particular has focused on ACOs as a primary device to improve quality and reduce costs.

Objective

To examine whether the current Medicare ACOs are likely to be successful.

Discussion

Patients receiving care in ACOs have little incentive to use low-cost quality providers. Furthermore, the start-up costs of ACOs for providers are high, contributing to the minimal financial success of ACOs. We review issues such as reducing readmissions, palliative care, and the difficulty in coordinating care, which are major cost drivers. There are mixed incentives facing hospital-controlled ACOs, whereas physician-controlled ACOs could play hospitals against each other to obtain high quality and cost reductions. This discussion also considers whether the current structure of ACOs is likely to be successful.

Conclusion

The question remains whether Medicare ACOs can achieve the Triple Aim of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” Care coordination in ACOs and information technology are proving more complicated and expensive to implement than anticipated. Even if ACOs can decrease healthcare costs and increase quality, it is unclear if the current incentives system can achieve these objectives. A better public policy may be to implement a system that encompasses the best practices of successful private integrated systems rather than promoting ACOs.     

Legal Mechanisms Supporting Accountable Care Principles

Public health and private providers and facilities may shape the future of the US health system by engaging in new ways to deliver care to patients.“Accountable care” contracts allow private health care and public health providers and facilities to collaboratively serve defined populations. Accountable care frameworks emphasize health care quality and cost savings, among other goals.In this article, I explore the legal context for accountable care, including the mechanisms by which providers, facilities, and public health coordinate activities, avoid inefficiencies, and improve health outcomes. I highlight ongoing evaluations of the impact of accountable care on public health outcomes.As the US health system undergoes transformation, public health departments are engaging in new ways to deliver health care with private entities. One such method is “accountable care,” the coordinated provision of patient services by health care and public health providers and facilities with the goals of improving outcomes and avoiding inefficiencies.1 The core tenets of accountable care are prevention, health care quality, patient satisfaction for the population served, and cost savings to the health care system.1 Accountable care frameworks are based on risk and reward, with providers and facilities agreeing to collectively share the financial risk for a population in return for the opportunity to access rewards for attaining preestablished health care goals.Entities that seek to engage in accountable care are formed according to legal principles governing businesses and contracts, but federal and state laws2 specifically incentivize the formation and success of these entities by establishing antitrust waivers, fraud and abuse protections, and mandates to coordinate care. Although much has been written on the legal basis for establishing accountable care entities, with this article, I seek to inform public health practitioners of the relationship between the laws that recognize accountable care principles and the public health goals of improving patient care, impacting quality and outcomes, and measuring population health.In this article, I discuss 3 mechanisms by which providers, facilities, and public health may contract together to maintain legal entities that implement accountable care principles. First, health care providers and payers have pursued private contracts to provide accountable care to improve outcomes in their patient populations.3 Second, the Centers for Medicare and Medicaid Services authorizes Medicare reimbursements for legal entities certified as accountable care organizations (ACOs) through traditional fee-for-service and other payments upon meeting benchmark cost and quality standards.4 Third, state laws incorporate accountable care mechanisms into Medicaid provisions, permitting state programs to reimburse accountable care entities that serve vulnerable populations.5 Finally, I offer suggestions for evaluating the impacts of accountable care on public health outcomes.