vii
Contents
Preface ....................................................................................................... xi
Introduction ..............................................................................................xv
1 Reforming the Private Insurance Industry ........................................ 1
Private Insurance Industry in the United States ......................................3
Reforming the Private Insurance Industry ..............................................4
Flaws in the Patient Protection and Aordable Care Act ........................8
Strengthening the Health Care Reform Legislation .............................. 15
Notes .................................................................................................... 17
2 How Will Health Care Reform Aect the Medicare and
Medicaid Populations? .................................................................... 19
About Medicare ....................................................................................21
How Does the Health Care Reform Legislation Change Medicare
and Medicaid? ......................................................................................24
Independence at Home Program .................................................25
Medical Homes ...........................................................................25
Accountable Care Organizations .................................................27
Extension Program Hub ..............................................................31
Community Health Centers ........................................................32
Lowering Medicare and Medicaid Costs ...............................................33
State Governments and MedicaidMedicare Reform ..................34
Lowering Health Care Costs through Health Care Reform .........35
Notes ....................................................................................................38
3 Can We Lower Health Care Costs by Eliminating Waste? .............. 41
Medical Waste and Economic Waste ....................................................43
Cost–Benet Analysis ...........................................................................45
Controlling Medical and Economic Waste ...........................................46
Medical Spending during the Last Days of Life ...........................47
Patient Protection and Aordable Care Act and Waste ................49
viii ◾  Contents
Placing the Burden of Cost Control on the Patient ......................49
Placing Responsibility for Decreasing Waste on Hospitals ...........50
Unintended Consequences of Attempts to Eliminate Waste ........ 51
Developing a Rational and National Strategy to
Reduce Waste .............................................................................. 51
Notes .................................................................................................... 55
4 Role of Disease Prevention in Health Care Reform ........................ 57
Prevention and Wellness Programs in the Patient Protection and
Aordable Care Act ..............................................................................60
Section 2705 of the Patient Protection and Aordable Care
Act—Legislating Wellness! .......................................................... 61
U.S. Preventive Services Task Force: Another Potential Flaw
in the Patient Protection and Aordable Care Act .......................62
Prevention Doesnt Lower Health Care Costs—It Might
Actually Increase em! ...............................................................63
Addressing the Epidemic of Obesityand Health
Care Reform ................................................................................ 65
Complex Social and Economic Issues of the
Obesity Epidemic ...............................................................65
Individuals Must Often Support the Costs of Prevention ............ 67
Steps to Ensure Prevention and Wellness ..............................................68
Notes ....................................................................................................70
5 How Will Health Care Reform Aect the Medically
Underserved and the Safety Net Hospitals at Care
for em? ......................................................................................... 73
Health Care Safety Net......................................................................... 76
History of Safety Net Hospitals ............................................................77
Disproportionate-Share Hospital Payments ..........................................79
Safety Net Hospitals Falter When DSH Funds Are
Redirected to Pay for Health Insurance .......................................80
Patient Protection and Aordable Care Act reatens the
Country’s Safety Net ...................................................................80
Pay-for-Performance Can Also reaten Safety
Net Hospitals ...............................................................................81
Health Care Exchange ..........................................................................82
Will the Exchanges Work? ...........................................................84
Some States Are ahead of the CurveOthers behind It .......................86
Health Care Reform in Massachusetts: A Template for
Health Care Exchanges? ..............................................................87
Contents ◾  ix
How Can the Patient Protection and Aordable Care Act Be
Modied to Protect the Safety Net? ......................................................88
Notes ....................................................................................................90
6 How Can We Improve the Quality of Care in the
United States? .................................................................................. 93
e Cost–Quality Conundrum ............................................................95
e Dartmouth Atlas and Health Care Reform .....................................97
Measuring Quality of Care .................................................................100
Measuring Quality of Care: e Health Care Reform
Legislation ................................................................................. 101
Pay-for-Performance .................................................................. 102
Electronic Health Record .......................................................... 103
Value-Based Purchasing ............................................................. 103
Substantive Steps Taken by the Patient Protection and Aordable
Care Act..............................................................................................104
What Additional Steps Should Congress Take to Ensure Quality
of Care? ...............................................................................................106
Notes .................................................................................................. 109
7 Will ere Be Enough Doctors to Care for 35 Million New
Patients? ......................................................................................... 113
How Does the Patient Protection and Aordable Care Act
Address the Workforce Crisis? ............................................................. 116
e 1997 Balanced Budget Act and the Health Care Workforce
Crisis................................................................................................... 118
Changing Demographics of the Physician Workforce .................119
Workforce Crisis Is Not in Primary Care Alone ........................120
Lessons from Massachusetts ...................................................... 121
How Have We Approached the Need to Increase the Number of
Practicing Physicians in the United States? ......................................... 121
Danger around the Corner .................................................................124
What Should We Do to Increase the Size of the Health Care
Workforce? ..........................................................................................125
Notes ..................................................................................................128
8 Can Research Guide Us to Improved Care at Lower Costs? .......... 131
Why Comparative–Eectiveness Research Has Become a
Lightning Rod in the Health Care Debates ........................................134
Patient Protection and Aordable Care Act and Comparative-
Eectiveness Research ......................................................................... 135
Potential Value of Comparative-Eectiveness Research ......................136
x ◾  Contents
Can Comparative-Eectiveness Research Lower Costs? ......................138
Limitations of Comparative-Eectiveness Studies ...............................140
Using Comparative-Eectiveness Research .........................................142
Notes .................................................................................................. 144
9 How Will Health Care Reform Change the Way We
Practice Medicine? ......................................................................... 147
Physician Compensation ..................................................................... 149
Sustainable Growth Rate .................................................................... 150
How Did the Patient Protection and Aordable Care Act
Change the Way Doctors Are Paid? .....................................................151
Pay-for-Performance .................................................................. 152
Payment Bundling ..................................................................... 153
Global Payment ......................................................................... 154
Electronic Health Records ......................................................... 156
Multispecialty Group Practices .................................................. 159
e Independent Payment Advisory Board ................................160
How Can the Patient Protection and Aordable Care Act
Be Improved? ...................................................................................... 161
Notes .................................................................................................. 163
10 Will We Ever See Tort Reform in the United States? ..................... 165
Current Tort System ........................................................................... 167
Malpractice Caps ................................................................................ 170
Patient Protection and Aordable Care Act Failed to Address Tort
Reform ................................................................................................ 171
Medical MalpracticeA Silent Disease .............................................. 172
Employment Law and the Health Professions ..................................... 173
It Is Not Too LateNovel Strategies for Reforming Our
Tort System ......................................................................................... 174
Notes .................................................................................................. 176
11 Conclusion ..................................................................................... 179
Surviving Health Care Reform ........................................................... 186
Notes .................................................................................................. 188

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