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Vidhya Alakason scrutinises US healthcare legislation

19 Apr, 10 | by BMJ Group

The champagne glasses have been put away in Washington DC . It is now time for the hard work of implementing the pages of provisions included in the health reform bill that was passed by Congress last month.  While the media coverage has rightly focused on the historic extension of health insurance to cover most of the 47 million uninsured Americans, the legislation contains many other provisions that are worth a closer look, particularly in light of current priorities within the NHS.
 
The legislation includes several pilots and new grant programs that are trying to improve the efficiency and improve the quality of care for the highest cost patients with multiple chronic conditions in the Medicare programme for older adults. As the NHS continues to search for effective ways to make care across hospitals and outpatient settings, and across health and social care seamless to patients, there may be some interesting ideas that emerge from the US . The most interesting provisions focus on creating financial incentives to improve and join up chronic care. One proposed pilot will implement a bundled payment to cover care up to three days before and thirty days after hospitalisation. Another includes the possibility of sharing savings from improvements in chronic care between a group of providers known as an accountable care organisation and the Medicare program.
 
Prevention gets a good deal of attention in the legislation – another area where the NHS and other developed country health systems are paying more and more attention. Here too there is a strong focus on financial incentives. The legislation increases by 10% the premium discount that employers can offer employees who enrol in wellness activities such as smoking cessation. It also requires the main public insurance plans, Medicare and Medicaid, to develop financial incentive programs to encourage individuals to adopt healthier lifestyles and take up preventative care.
 
Quality measurement also features strongly in health reform. As in other countries, the development of quality measures is coupled with efforts to increase the transparency of quality information, for example through the development of a Physician Compare website for use by Medicare patients. Over time, the bill proposes linking payment more closely to quality along similar lines to the Quality and Outcomes Framework for GPs in England. A physician payment modifier based on quality and cost will be phased in for the Medicare programme between 2015 and 2017.
 
Finally, the legislation kicks off a major experiment in the financing of long term care. The CLASS program that was included in the bill is a national, voluntary long term care insurance program. All working adults will be automatically enrolled unless they choose to opt out and after a five year vesting period, the program will pay out a cash benefit to individuals with functional limitations. Voluntary insurance is one option that the UK has considered as part of its efforts to reform social care financing. With no decision yet made as to how to create a sustainable funding stream with an aging population, the extent to which America’s new insurance program manages to balance its books will be interesting to watch.
 
It will be some time before we can say anything about the impact of these provisions. Implementation will take place over the next ten years and it is entirely possible that future legislation will amend some of the current provisions. There is also a risk that many of the pilot provisions will never amount to anything more and that sweeping changes will never made. That said, health reform legislation in the US has kicked off an exciting phase of experimentation from which we could all benefit.

Vidhya Alakeson is a former Harkness Fellow in Healthcare Policy who was based in Washington DC until last month.

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