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UNITED STATES adopted at least a basic EHR system, representing an eightfold increase since 2008 (Heisey-Grove and Patel, 2015; Charles et al., 2015). The Meaningful Use Incentive Program is designed to gradually raise the threshold for EHR functionality above which providers receive incentives and avoid penalties. The current focus is on information exchange. How are costs contained? Annual per capita health expenditures in the United States are the highest in the world ($9,086 in 2013), despite a recent slowdown in spending (OECD, 2015). Payers have attempted to control cost growth through a combination of selective provider contracting, price negotiations and controls, utilization control practices, risksharing payment methods, and managed care. Recently, both public and private payers have focused more attention on value-based purchasing and other models that reward effective and efficient health care delivery. A movement toward favoring generic drugs over brand-name drugs, meanwhile, has led to a slowdown in pharmaceutical spending in recent years, although growth rebounded in 2014. Another growing trend is the increase in private insurance plans with high deductibles. A number of reforms included in the ACA attempt to develop payment methods in the Medicare and Medicaid programs that reward high-quality, efficient care. Some of these use pay-for-performance mechanisms, whereas others rely on bundled payments, shared savings, or global budgets to incentivize integration and coordination among health care providers. Despite a recent slowdown in health care spending, the latest data, through August 2015, show that spending grew 5.7 percent in the past year (Altarum Institute, 2015). What major innovations and reforms have been introduced? The Affordable Care Act, which ushered in a sweeping series of insurance and health system reforms aimed at achieving near-universal coverage, improved affordability, higher quality, greater efficiency, lower costs, strengthened primary and preventive care, and expanded community resources, has survived. There have been modifications to the law, however, as a result of several Supreme Court decisions since 2010. Perhaps most notable was the 2012 ruling that made the expansion of Medicaid optional for states: because of that decision, only 30 of 50 states (in addition to the District of Columbia) have pursued expansion as of late 2015. Still, since implementation of the ACA in 2013, the number of uninsured adults has declined by historic proportions (Collins et al., 2015). Groups that have been long been at greatest risk of being uninsured—young adults, Hispanics, blacks, and those with low income—have made the greatest coverage gains (Blumenthal et al., 2015). In 2015, the Department of Health and Human Services announced a goal to move 50 percent of Medicare payments to alternative payment models, including ACO-based arrangements, by 2018 (Blumenthal et al., 2015; Muhlestein, 2015). Medicare also has begun paying for doctors to coordinate the care of patients with chronic conditions. To be eligible for an extra $40 per patient, doctors must draft and help carry out a comprehensive plan of care for each patient who signs up for one. Under federal rules, those patients have access to doctors or other health care providers on a doctor’s staff 24 hours a day, seven days a week, to deal with “urgent chronic care needs” (Edwards and Landon, 2014). In April 2015, the Senate passed the Medicare “doc fix,” averting an imminent cut in Medicare physician fees that was scheduled to occur under the now-repealed sustainable growth rate (SGR) formula. While the SGR was designed to counter the tendency toward spending growth inherent in the fee-for-service model, it was a flawed model. It was replaced by an approach focusing on rewarding high-performing providers and supporting alternative payment models (Guterman, 2015). 178 The Commonwealth Fund
References UNITED STATES Altarum Institute (2015). “Health Sector Economic Indicators—Insights from Monthly National Health Spending Data Through August 2015,” Oct. 2015. http://altarum.org/sites/default/files/uploaded-related-files/CSHS-Spending-Brief_ October_2015_0.pdf. Assistant Secretary for Planning and Evaluation (ASPE) (2014). ASPE Federal Medical Assistance Percentages (FMAP) 2014 Report, https://aspe.hhs.gov/basic-report/fy2014-federal-medical-assistance-percentages. Assistant Secretary for Planning and Evaluation (ASPE) (2015a). Health Insurance Coverage and the Affordable Care Act. Assistant Secretary for Planning and Evaluation (ASPE) (2015b). U.S. Federal Poverty Guidelines Used to Determine Financial Eligibility for Certain Federal Programs. http://aspe.hhs.gov/2015-poverty-guidelines. Blumenthal, D., M. K. Abrams, R. Nuzum (2015). “The Affordable Care Act at Five Years.” New England Journal of Medicine, Online First, May 6, 2015, http://www.commonwealthfund.org/publications/in-brief/2015/may/affordable-care-act-at-five. Centers for Medicare and Medicaid Services (CMS) (2015a). National Health Expenditure Data, https://www.cms.gov/ research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html. Centers for Medicare and Medicaid Services (CMS) (2015b). https://www.cms.gov/Newsroom/MediaReleaseDatabase/Pressreleases/2015-Press-releases-items/2015-08-25.html. Charles, D., Gabriel, M., Searcy, T. “Adoption of Electronic Health Record Systems among U.S. NonFederal Acute Care Hospitals: 2008–2014,” ONC Data Brief No. 23, April 2015, https://www.healthit.gov/sites/default/files/data-brief/2014Hospi talAdoptionDataBrief.pdf. Collins, S. R., P. W. Rasmussen, M. M. Doty, S. Beutel (2015). Americans’ Experiences with Marketplace and Medicaid Coverage—Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March–May 2015. New York: The Commonwealth Fund. Commonwealth Fund (2015). Medicaid Expansion Map. http://www.commonwealthfund.org/interactives-and-data/mapsand-data/medicaid-expansion-map. Congressional Budget Office (CBO) (2015). Insurance Coverage Provisions of the Affordable Care Act—CBO’s March 2015 Baseline, https://www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2015-03-ACAtables.pdf. Edwards, S. T., B. E. Landon (2014). “Medicare’s Chronic Care Management Payment—Payment Reform for Primary Care.” New England Journal of Medicine 371(22):2049–51. http://www.nejm.org/doi/full/10.1056/NEJMp1410790. Guterman, S. (2015). “With SGR Repeal, Now We Can Proceed with Medicare Payment Reform. Commonwealth Fund Blog, April 15, 2015. http://www.commonwealthfund.org/publications/blog/2015/apr/repealing-the-sgr. Healthcare.gov (2015). Out-of-pocket maximum/limit. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/. Heisey-Grove, D., Patel, V. “Any, Certified and Basic: Quantifying Physician HER Adoption Through 2014,” ONC Data Brief No. 28, Sept. 2015. https://www.healthit.gov/sites/default/files/briefs/oncdatabrief28_certified_vs_basic.pdf. Henry J. Kaiser Family Foundation (2015a). Number of Dual Eligible Beneficiaries, http://kff.org/medicare/state-indicator/ dual-eligible-beneficiaries/. Henry J. Kaiser Family Foundation (2015b). Distribution of Certified Nursing Facilities by Ownership Type, http://kff.org/ other/state-indicator/nursing-facilities-by-ownership-type/. Medicaid.gov (2014). FY 2014 Unduplicated Number of Children Ever Enrolled in Medicaid and CHIP. http://medicaid.gov/ chip/downloads/fy-2014-childrens-enrollment-report.pdf. Muhlestein, D. (2015). “Growth and Dispersion of Accountable Care Organizations in 2015.” Health Affairs Blog, March 31, 2015. http://healthaffairs.org/blog/2015/03/31/growth-and-dispersion-of-accountable-care-organizations-in-2015-2/. National Bureau of Economic Research (NBER) (2014). Tax Breaks for Employer-Sponsored Health Insurance. Organisation for Economic Co-operation and Development (OECD) (2015). Health Data. Osborn, R., D. Moulds, E. C. Schneider, M. M. Doty, D. Squires, D. O. Sarnak (2015). “Primary Care Physicians in Ten Countries Report Challenges Caring for Patients with Complex Health Needs.” Health Affairs 34(12):2104–2112. Rice, T., P., Rosenau, L. Y., Unruh et al. “United States of America: Health System Review,” Health Systems in Transition, 2013 15(3):1–431. U.S. Census Bureau (2014). Health Insurance Coverage in the United States: 2014 –Current Population Reports. http://www. census.gov/content/dam/Census/library/publications/2015/demo/p60-253.pdf. International Profiles of Health Care Systems, 2015 179
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
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AUSTRALIA In 2013, the federal gove
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What is being done to reduce dispar
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References AUSTRALIA Australian Bur
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CANADA What is covered? Services: T
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CANADA funding to 145 not-for-profi
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CANADA Organization of the Health S
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CANADA provides recommendations to
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CANADA Health Council of Canada (20
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CHINA Private health insurance: Com
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CHINA is not substantially more exp
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CHINA Organization of the Health Sy
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CHINA References Chen, X. (2014).
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DENMARK In addition, nearly 1.5 mil
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DENMARK Social psychiatry and care
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DENMARK Quality data for a number o
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DENMARK portion is small, it makes
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ENGLAND immunization, and vaccinati
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ENGLAND Hospitals: Publicly owned h
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ENGLAND Organization of the Health
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ENGLAND How are costs contained? Ra
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ENGLAND Organisation for Economic C
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FRANCE VHI finances 13.8 percent of
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FRANCE The average income of primar
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FRANCE What are the key entities fo
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FRANCE inequities in prevention rel
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FRANCE Nolte, E., C. Knai, and M. M
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GERMANY There were 42 substitutive
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GERMANY The 16 state governments de
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GERMANY management system, by the s
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GERMANY What major innovations and
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INDIA Private health insurance: The
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INDIA provide after-hour care, reim
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INDIA are provided by other ministr
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INDIA How are costs contained? Ther
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ISRAEL Together, these two types of
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ISRAEL Primary care physicians are
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ISRAEL Organization of the Health S
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ISRAEL • Using electronic health
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ITALY during hospitalization (Thoms
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ITALY Some regions are promoting ca
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ITALY Organization of the Health Sy
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ITALY although the degree of evolut
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ITALY The author would like to ackn
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JAPAN What is covered? Services: Al
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JAPAN incentives for providers to c
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JAPAN Organization of the Health Sy
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JAPAN The author would like to ackn
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THE NETHERLANDS receive faster acce
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THE NETHERLANDS Hospital payment ra
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THE NETHERLANDS Organization of the
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THE NETHERLANDS References Organisa
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NEW ZEALAND provided in GP clinics.
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NEW ZEALAND management (e.g., clean
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