Rethinking Healthcare in the United States

Background

Rethinking Healthcare in the United States Background : The healthcare system of the United States Introduction – The U.S. healthcare system (USHCS) is composed of public and private, for profit and non-profit/not-for-profit insurers and providers. Federal, state, and local governments provide funding for some of the population; however, private insurance remains the dominant payor, and it is generally provided (although not necessarily fully funded) by employers. Notable government programs include Medicare, Medicaid, multiple programs for veterans, and the Children’s Health Insurance Program (CHIP).

In 2010 when the Affordable Care Act (ACA) was passed, 16% of the population was uninsured; approximately 8.5% of the population, or 27 million people, remain uninsured today. Given this profile, how does the USHCS compare to other developed countries that are members of the Organization for Economic Co-operation and Development (OECD)?

Recent data from the Peter G. Peterson Foundation (How Does the U.S. Healthcare System Compare to Other Countries? (pgpf.org)) and OECD (health-at-a-glance-united-states-EN.pdf (oecd.org)) strongly suggest weaker comparative performance by the U.S. Some key data are illustrative: ?

The U.S. spends more as a proportion of GDP (17.0%) than any other OECD country. Between 2010 and 2019, spending on health across the OECD averaged about 8.7% of GDP annually. Also, healthcare spending in the U.S. rose from 16.3% to 17% of GDP in that same time period. On a per-capita basis, in 2019, the U.S. spent approximately $19,000 on healthcare, while Switzerland, the second-highest spending OECD country, spent $7,700 per capita. If you exclude the U.S., the average per capita spending on healthcare in the OECD was $5,500. If current trends continue, U.S. spend¬ing on healthcare may reach 20% of GDP by 2030. ?

Other key indicators where the U.S. fares worse than the OECD average Key Indicator U.S. OECD

• Life expectancy 78.6 80.7

• Avoidable mortality (deaths per 100,000) 262 208

• Chronic disease morbidity (diabetes prevalence %) 10.8 6.4

• Overweight / obese (% population with BMI > 25) 71.0 55.6

• Population coverage (% population covered by government schemes / insurance) 91.0 98.0

• Financial protection (% spending from public sources) 50.0 71.0

• Service coverage, primary care (% adults with access to a doctor when needed) 65.0 79.0

Note: these data are from OECD as of 2019 and are pre-COVID pandemic. The Commonwealth Fund (United States | Commonwealth Fund) has prepared a schematic of the current USHCS that documents its complexity. Additional related data are contained in the table that follows: Key U.S. demographics from the Commonwealth Fund (all data as of December 2020) Demographic U.S.

Introduction to the U.S. healthcare system

• Total population 325.7 million

• Population age 65+ 16.0%

• Practicing physicians per 1,000 population 2.6

• Average physician visits per person 4.0

• Nurses per 1,000 population 11.7

• Hospital beds per 1,000 population 2.8

• Hospital discharges per 1,000 population 125

• Out-of-pocket health spending per capita $1,122

• Spending on pharmaceuticals (prescription and OTC) per capita $1,220

• Adults with multiple chronic conditions (2 or more) 28.0% Current Situation It is noteworthy that U.S. Department of Health and Human Services (DHHS) released data on June 5, 2021, which showed more Americans have obtained health coverage through the ACA than ever before. Some notable statistics:

• 31 million have health coverage through the ACA, including 11.3 million enrolled in the ACA Marketplace plans and 14.8 million newly eligible people enrolled in Medi-caid through the ACA’s expansion of eligibility to adults as of December 2020.

• One million enrolled in the ACA’s Basic Health Plan and nearly 4 million previously eligible adult Medicaid enrollees who gained coverage under the expansion.

• Between 2010 and 2016, the number of nonelderly uninsured adults decreased by 41% to 28.2 million. This reduction occurred in all states and the District of Colum-bia. Note that 13 states have not expanded Medicaid to cover adults under the ACA. It seems clear from the data summarized above that the United States is not getting maximum value from the considerable amount of money being spent on healthcare. Not only are we pay-ing significantly more than any other OECD country, but outcomes are often among the poorest reported by the 38 members of the organization. Further, the U.S experience with the COVID epidemic has highlighted shortcomings in access, testing, prevention, public education, messag-ing/communication, and the medical supply chain that must be addressed. Consequential action

– The Secretary DHHS, in response to concerns raised by the public, leaders of Congress, and the President has been tasked with rethinking healthcare in the United States. She has formed a task force and named your team to reimagine how healthcare should be struc¬tured and operated. This is a once-in-a-lifetime opportunity to start over and develop a new U.S. healthcare system (USHCS 2.0). Key considerations

– USHCS 2.0 should align with the Triple-Aim framework developed by the Institute for Healthcare Improvement (IHI). The IHI framework defines a process to opti-mize health system per¬formance through three dimensions (hence the Triple-Aim):

Comparison to other developed countries

1. Improving the patient experience of care, including quality and satisfaction,

2. Improving the health of populations, and

3. Reducing the per capita cost of healthcare. Put more succinctly, the objectives can be categorized as quality, access, and cost. This notably does not include political feasibility. While realistically that is a non-trivial issue, for the initial recommendations, we want the best possible solution. Once in hand, there will be compromises required to assuage political realities, but that process will occur at a later time.

The recom-mended system must be technically and procedurally realistic to begin with. At a minimum, the Secretary requires that USHCS 2.0 addresses the elemental structural and functional shortcomings of the current U.S. healthcare system:

Element 1: Management And Leadership The current U.S. healthcare system is an assemblage of discrete parts from the private and pub¬lic sectors. It has no overall leadership nor is any one individual or organization respon-sible for its functioning. The fact that there are competing interests alone is a major contrib-utor to its lack of efficiency. There is a vague belief that market forces will impose optimal solutions. Clearly, the results argue otherwise.

Element 2: Plannng And Preparation With no centralized management structures or processes, purposeful planning and prepara-tion are largely incoherent. Recent experiences with the ACA implementation and with COVID clearly demonstrate the lack of coordination and alignment of goals and objectives between the federal government and the states. Additional misalignment between the public sector and private sector positions relating to financial objectives are stark. Finally, the recurring changes in politi¬cal leadership at multiple levels indicate the fragility of long-term plans, and subsequent deci¬sion-making and solution sustainability.

Element 3: Desgin As the current U.S. healthcare system evolved mostly organically, it consists of disparate pieces forced to coexist and interact. Interoperability occurs sub-optimally which introduces delays and higher administrative expense. While some elements of the current sys-tem are designed to maximize profits, other parts are designed to maximize service, quality, or access. Inevitably there are operating inefficiencies due to incongruent goals and ob-jectives.

Element 4: Execution Healthcare system planning and operations are clearly hampered by multiple factors includ-ing decentralized leadership, lack of plan coordination, budget volatility, shifting political values and priorities, and growing public impatience. An additional complicating factor results from the stresses placed on the health delivery function due to shortages (e.g., staff, supplies, beds) which accumulate and lead to staff burnout, early retirement, treatment inequities, medical errors, and more recently, harassment of healthcare workers.

Key indicators of U.S. healthcare performance

Element 5: Communications Communication is a particularly concerning issue. With competing spheres of management and leadership, there is little consistent messaging. With a lack of widespread common motivation among the many actors, there is minimal convergence of goals and objectives reaching the public. Finally, there is no unified source of information that is trusted equally by all stakeholders. The results are a filtered stream of truths, half-truths, and outright falsehoods coming from multiple sources all competing for credibility. The lack of a common set of accepted facts is a contributing factor to the previous points. The approach – The Secretary DHHS has defined a 3-phase approach for creating USHCS 2.0).

Phase 1 – Develop the key attributes for a conceptual design of USHCS 2.0, considering the objectives of the Triple-Aim and providing remedies for the five structural shortcomings listed above.

Phase 2 – Prepare a detailed design of USHCS 2.0 including a rollout strategy.

Phase 3 – Implement USHCS 2.0. Your Assignment The product – Your team has been assigned the responsibility for developing the management plan that will act as the Phase 1 project roadmap. The plan will be used to manage the project that will, at a minimum, determine the requirements for USHCS 2.0, the approach to be fol-lowed by the requirements team, team organization, communications, reporting relationships, status reporting procedures, and the identification of key skill sets required for project team members. The management plan should ensure that the following six solution descriptors will be produced during

Phase 1: Descriptor 1: The Proposed USHCS 2.0 Describe your proposed revised healthcare system, including its

a. Mission, values, and objectives

b. Major components

c. Advantages over the current healthcare system. If there are any disadvantages they should be described too

d. Management structure (top-down national control, regional / state control, pri-vate control, a mixture, etc.)

Descriptor 2: Stakeholders Identify critical stakeholders and how to establish and maintain communications with all of them during all three phases of the approach defined above.

Descriptor 3: Funding Identify anticipated funding mechanisms or simply repurpose existing mechanisms (i.e., private insurance premiums, employer funding, Medicare withholding, state funding, direct taxation, etc.). Note that the proposed funding mechanisms must comport with the way the redesigned system will be constructed. For example, if there will no longer be private health insurance plans then there may not be a need for private insurance premiums. This is not a requirement to develop a budget – it is asking for a discussion of sources and mechanisms.

Descriptor 4: Barriers Identify and discuss potential barriers to implementation and, where possible, general mitigation strategies.

Descriptor 5: Transition Discuss the transition process to reach your recommended solution. While this will ultimately be a major consideration, your report should address this topic in a very general way. There is no need to prepare a detailed transition plan; only identify major issues you believe may need to be addressed at a future date. For example, one major consideration might be the issue of interoperability among HIT systems across the national healthcare spectrum; another might be creating universal standards for electronic health records and determining how to convert legacy records to the new standards.

Descriptor 6: Timing Offer guidance on the timeframes required to achieve major milestones such as design, develop, test, convert, and implement the proposed solution. Timeframes need not be calendar based, the objective here is to offer broad estimates of how long it might take to achieve the major USHCS 2.0 milestones. Response guidance – To be clear, you are to prepare the management plan to conduct Phase 1 which will, in turn, meet Phase 1’s objectives. Your response should include all assump¬tions you make in formulating your answer. It should be clear how the Phase 1 project will be able to address each of the solution descriptors listed above. Your response should include a narrative description of your management approach, along with a detailed listing of activities and tasks (similar to a workplan) that, if followed, will lead to a successful

Phase 1 conclusion. Document requirements – Your report should adhere to the following format:

1. There is no specific length requirement for the document. It should be exactly as long as required for you to meet the objectives fully.

2. A minimum of six peer-reviewed sources are to be used in the development of your re-sponse. All should be cited at least once and appear in your references.

3. All topics listed in “The product” subsection above must be addressed. Headings and subheadings should reflect topics in a logical way.

4. APA 7 guidelines for a non-publishable article should be followed in preparing the document.