The Physicians' Working Group for Single-Payer National Health Insurance*
JAMA. 2003;290:798-805.
The United States spends more than twice as much on health careas the average of other developed nations, all of which boastuniversal coverage. Yet more than 41 million Americans haveno health insurance. Many more are underinsured. Confrontedby the rising costs and capabilities of modern medicine, othernations have chosen national health insurance (NHI). The UnitedStates alone treats health care as a commodity distributed accordingto the ability to pay, rather than as a social service to bedistributed according to medical need. In this market-drivensystem, insurers and providers compete not so much by increasingquality or lowering costs, but by avoiding unprofitable patientsand shifting costs back to patients or to other payers. Thiscreates the paradox of a health care system based on avoidingthe sick. It generates huge administrative costs that, alongwith profits, divert resources from clinical care to the demandsof business. In addition, burgeoning satellite businesses, suchas consulting firms and marketing companies, consume an increasingfraction of the health care dollar. We endorse a fundamentalchange in US health carethe creation of an NHI program.Such a program, which in essence would be an expanded and improvedversion of traditional Medicare, would cover every Americanfor all necessary medical care. An NHI program would save atleast $200 billion annually (more than enough to cover all ofthe uninsured) by eliminating the high overhead and profitsof the private, investor-owned insurance industry and reducingspending for marketing and other satellite services. Physiciansand hospitals would be freed from the concomitant burdens andexpenses of paperwork created by having to deal with multipleinsurers with different rules, often designed to avoid payment.National health insurance would make it possible to set andenforce overall spending limits for the health care system,slowing cost growth over the long run. An NHI program is theonly affordable option for universal, comprehensive coverage.
The financing and delivery of long-term care (LTC) need substantial reform. Many cannot afford essential services; age restrictions often arbitrarily limit access for the nonelderly, although more than a third of those needing care are under 65 years old; Medicaid, the principal third-party payer for LTC, is biased toward nursing home care and discourages independent living; informal care provided by relatives and friends, the only assistance used by 70% of those needing LTC, is neither supported nor encouraged; and insurance coverage often excludes critically important services that fall outside narrow definitions of medically necessary care. We describe an LTC program designed as an integral component of the national health program advanced by Physicians for a National Health Program. Everyone would be covered for all medically and socially necessary services under a single public plan, federally mandated and funded but administered locally. An LTC payment board in each state would contract directly with providers through a network of local public agencies responsible for eligibility determination and care coordination. Nursing homes, home care agencies, and other institutional providers would be paid a global budget to cover all operating costs and would not bill on a per-patient basis. Alternatively, integrated provider organizations could receive a capitation fee to cover a broad range of LTC and acute care services. Individual practitioners could continue to be paid on a fee-for-service basis or could receive salaries from institutional providers. Support for innovation, training of LTC personnel, and monitoring of the quality of care would be greatly augmented. For-profit providers would be compensated for past investments and phased out. Our program would add between $18 billion and $23.5 billion annually to current spending on LTC. Polls indicate that a majority of Americans want such a program and are willing to pay earmarked taxes to support it. 相似文献
We review evidence on the value of dipstick urinalysis screening for hemoglobin and protein in asymptomatic adults. In young adults, evidence from five population-based studies indicates that fewer than 2% of those with a positive heme dipstick have a serious and treatable urinary tract disease, too few to justify screening and the risks of subsequent workup. For older populations, evidence is contradictory and no recommendation can presently be made for or against hematuria screening. A population-based randomized, controlled trial of hematuria screening in the elderly is urgently needed. Proteinuria screening is not recommended in any healthy, asymptomatic adult population, since four population-based studies have found that fewer than 1.5% of those with positive dipsticks have serious and treatable urinary tract disorders. 相似文献
BACKGROUND Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists
and primary care providers can further compromise post-discharge care. Redesigning the discharge process may improve the continuity
and the quality of patient care.
OBJECTIVES To evaluate a low-cost intervention designed to promptly reconnect patients to their “medical home” after hospital discharge.
DESIGN Randomized controlled study. Intervention patients received a “user-friendly” Patient Discharge Form, and upon arrival at
home, a telephone outreach from a nurse at their primary care site.
PARTICIPANTS A culturally and linguistically diverse group of patients admitted to a small community teaching hospital.
MEASUREMENTS Four undesirable outcomes were measured after hospital discharge: (1) no outpatient follow-up within 21 days; (2) readmission
within 31 days; (3) emergency department visit within 31 days; and (4) failure by the primary care provider to complete an
outpatient workup recommended by the hospital doctors. Outcomes of the intervention group were compared to concurrent and
historical controls.
RESULTS Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the
historical controls. Notably, only 14.9% of the intervention patients failed to follow-up within 21 days compared to 40.8%
of the concurrent and 35.0% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group
were incomplete versus 31.3% in the concurrent and 31.0% in the historical controls.
CONCLUSIONS A low-cost discharge–transfer intervention may improve the rates of outpatient follow-up and of completed workups after hospital
discharge. 相似文献
Many believe that computerization will improve health care quality, reduce costs, and increase administrative efficiency. However, no previous studies have examined computerization's cost and quality impacts at a diverse national sample of hospitals.
Methods
We linked data from an annual survey of computerization at approximately 4000 hospitals for the period from 2003 to 2007 with administrative cost data from Medicare Cost Reports and cost and quality data from the 2008 Dartmouth Health Atlas. We calculated an overall computerization score and 3 subscores based on 24 individual computer applications, including the use of computerized practitioner order entry and electronic medical records. We analyzed whether more computerized hospitals had lower costs of care or administration, or better quality. We also compared hospitals included on a list of the “100 Most Wired” with others.
Results
More computerized hospitals had higher total costs in bivariate analyses (r = 0.06, P = .001) but not multivariate analyses (P = .69). Neither overall computerization scores nor subscores were consistently related to administrative costs, but hospitals that increased computerization faster had more rapid administrative cost increases (P = .0001). Higher overall computerization scores correlated weakly with better quality scores for acute myocardial infarction (r = 0.07, P = .003), but not for heart failure, pneumonia, or the 3 conditions combined. In multivariate analyses, more computerized hospitals had slightly better quality. Hospitals on the “Most Wired” list performed no better than others on quality, costs, or administrative costs.
Conclusion
As currently implemented, hospital computing might modestly improve process measures of quality but does not reduce administrative or overall costs. 相似文献