Healthcare Reform Checklist

Health systems often require tweaking, fine-tuning, and even reconstruction.


Healthcare legislation in countries in transition,Guest Posting emerging economies, and developing countries should permit – and use economic incentives to encourage – a structural reform of the sector, including its partial privatization.


· Universal healthcare vs. selective provision, coverage, and delivery (for instance, means-tested, or demographically-adjusted)

· Health Insurance Fund: Internal, streamlined market vs. external market competition

· Centralized system – or devolved? The role of local government in healthcare.

· Ministry of Health: Stewardship or Micromanagement?

· Customer (Patient) as Stakeholder

· Imbalances: overstaffing (MDs), understaffing (nurses), geographical distribution (rural vs. urban), service type (overuse of secondary and tertiary healthcare vs. primary healthcare)


· To amend existing laws and introduce new legislation to allow for changes to take place.

· To effect a transition from individualized medicine to population medicine, with an emphasis on the overall welfare and needs of the community

Hopefully, the new legal environment will:

· Foster entrepreneurship;

· Alter patterns of purchasing, provision, and contracting;

· Introduce constructive competition into the marketplace;

· Prevent market failures;

· Transform healthcare from an under-financed and under-invested public good into a thriving sector with (more) satisfied customers and (more) profitable providers.

· Transition to Patient-centred care: respect for patients’ values, preferences, and expressed needs in regard to coordination and integration of care, information, communication and education, physical comfort, emotional support and alleviation of fear and anxiety, involvement of family and friends, transition and continuity.

The Law and regulatory framework should explicitly allow for the following:


(I1) Private health insurance plans (Germany, CzechRepublic, Netherlands), including franchises of overseas insurance plans, subject to rigorous procedures of inspection and to satisfying financial and governance requirements. Insured/beneficiaries will have the right to apply contributions to chosen purchaser and to switch insurers annually.

Private healthcare plans can be established by large firms; guilds (chambers of commerce and other professional or sectoral associations); and regions (see the subchapter on devolution under VI. Stewardship).

Private insurers: must provide universal coverage; offer similar care packages; apply the same rate of premium, unrelated to the risk of the subscriber; cannot turn applicants down; must adhere to national-level rules about packages and co-payments; compete on equality and efficiency standards.

(I11) Breakup of statutory Health Insurance Fund to 2-3 competing insurance plans (possibly on a regional basis, as is the case in France) on equal footing with private entrants.

Regional funds will be responsible for purchasing health services (including from hospitals) and making payments to providers. They will be not-for-profit organizations with their own boards and managerial autonomy.

(I12) Board of directors and supervisory boards of health insurance funds to include:

- Two non-executive, lay (not from the medical professions and not politicians) members of the public. These will represent the patients and will be elected by a Council of the Insured, (as is the practice in the Netherlands)

- Municipal representatives;

- Representatives of stakeholders (doctors, nurses, employees of the funds, etc.).

(I13) The funds will be granted autonomy regarding matters of human resources (personnel hiring and firing); budgeting; financial incentives (bonuses and penalties); and contracting.

The funds will be bound by rules of public disclosure about what services were purchased from which providers and at what cost.

Citizen juries and citizen panels will be used to assist with rationing and priority-setting decisions (United Kingdom).

(I2) Procurement of medicines to be done by an autonomous central purchasing agency, supervised by a public committee (drug regulatory authority) aided by outside auditors.

All procurement of drugs and medications will be done via international tenders.

The agency will submit its reimbursement rates for drugs on the PLD to external audit in order to accurately reflect pharmacists’ overhead costs. At the same time, the profit margins on all drugs, whether on the PLD or not, will be regulated.

This agency should be separate from the Health Insurance Fund and the Ministry of Health. This agency will also maintain national drug registries. It will secure volume discounts for bulk purchasing and transparent, arm’s-length pricing.

(I21) Use of reference prices for medicines. If the actual price exceeds the reference price, the price difference has to be met by the patient.

(I3) The Approved (Positive) List of Medicines will be recomposed to include generic drugs whenever possible and to exclude expensive brands where generics exist. This should be a requirement in the law. Separately, an Essential Drug List will be drawn up.

(I31) Encourage rational drug prescribing by instituting a mixture of GP and PHC incentives and penalties, or a fundholding system: budgets will be allocated to each GP for the purchase of drugs and medications. If the GP exceeds his/her budget, s/he is penalized. The GP gets to keep a percentage of budget savings. Prescription decisions will be medically reviewed to avoid under-provision.

(I4) Payments and Contracting

Payment to providers should combine, in a mixed formula:


Capitation – A fixed fee for a list of services to be provided to a single patient in a given period, payable even if the services were not consumed, adjusted for the patients’ demographic data and reimbursement for fee-for-service items.

Inflation-adjusted Global budgeting (hospitals) and block (lump sum) grants (municipalities)


Provide incentives and reward marketing efforts which result in an increase in
demand/referral beyond the limit set in a block contract.


Apply Diagnosis Related Group (DRG)/ Resource-based Relative Value (RBRV) / Patient Management Categories (PMCs) / Disease Staging/Clinical Pathways

Levels of reimbursement, case-mix adjusted to be decided by external auditors.

Contracts with providers should include:

· Waiting Times Guarantee

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On March 31, 2011, the Centers for Medicare and Medicaid Services (CMS) published its proposal to transform the Medicare program into one driven by the triple aim of obtaining better care for individuals, better health for populations and reducing per-capita costs. The proposed rule outlines how CMS will define the Accountable Care Organizations (ACOs) that will be eligible to participate in the Medicare Shared Savings Program.

On March 31,Guest Posting 2011, the Centers for Medicare and Medicaid Services (CMS) published its proposal to transform the Medicare program into one driven by the triple aim of obtaining better care for individuals, better health for populations and reducing per-capita costs. The proposed rule outlines how CMS will define the Accountable Care Organizations (ACOs) that will be eligible to participate in the Medicare Shared Savings Program. HEALTHYCIRCLES’ FOCUS ON THE TRIPLE AIMHealthyCircles Supports Better Care for IndividualsThe HealthyCircles Connected Health Platform fosters care coordination and evidence-based practice that improves patient satisfaction while supporting early interventions that can enhance patient outcomes.HealthyCircles Drives Better Health for PopulationsThe HealthyCircles Platform comes fully equipped with a unique Health Program Authoring Tool that allows an organization to build and deploy customized care protocols across populations that support CMS quality measure reporting while enabling providers to implement changes in care plans in response to clinical data.HealthyCircles Reduces Per-Capita CostsHealthyCircles enables organizations to provide efficient care and to enhance coordination across the care team. Data from interactive health trackers, pharmacy benefit managers (PBMs) and electronic medical records (EMRs) can be shared in order to manage redundant testing and to improve medical decision-making. HEALTHYCIRCLES’ FOCUS ON ENGAGEMENTHealthyCircles Engage enables organizations to engage with patients wherever they connect, through e-mail and popular social networking sites such as Facebook and Twitter. Engage allows ACOs to partner with patients and family caregivers to improve outcomes. WHY HEALTHYCIRCLES FOR THE SHARED SAVINGS PROGRAM?Organizations adopting the HealthyCircles Connected Health Platform can position themselves to participate in the Centers for Medicare and Medicaid Services program in January 2012 by leveraging these key features of HealthyCircles: • Care Solutions Library• Consumer Portal• Triage Dashboard for Population Health• Bi-Directional Data Exchange Hub• Patient-Centric Care Teams• HealthyCircles EngageThese HealthyCircles features provide the infrastructure that meets the goals of the Accountable Care Act and requirements for eligibility for shared savings. 1. PROMOTE EVIDENCE-BASED MEDICINEEvidence-based medicine is the application of the best available evidence gained from the scientific method and applied to clinical decision-making. Organizations wishing to participate as an ACO will need to select clinical guidelines that are linked to the effectiveness of medical treatment and to implement them at the organizational and institutional level. They will also be required to describe how they will adapt these guidelines as evidence changes or based upon the needs of their patients. The HealthyCircles Care Solution Library enables organizations to select and to customize health and disease management programs and intermittent patient assessments. Updating the programs is simplified by using the Program Authoring Tool. The changes can be instituted immediately and enable real-time, continuous quality improvement for distinct populations. 2. PROMOTE PATIENT ENGAGEMENTOrganizations will need to embrace patient engagement, which is the active participation of patients and their families in the process of medical decision-making. This concept includes ensuring that providers and patients embrace shared decision-making based upon the best possible treatment options within the context of their own needs and values. HealthyCircles’ Care Solutions deliver patient response-driven, evidence-based guidance that is linked to clinical protocols. The programs are aligned with educational content that is delivered to patients and families to support true, shared decision-making. 3. PROCESS TO REPORT QUALITY AND COST MEASURESIn order to be successful in managing risk within an ACO, the organization will need to be able to undertake population health management at the provider, practice and aggregate level. HealthyCircles enables organizations to build unique care teams around each patient, thus enabling an ACO using HealthyCircles to assign providers to patients and to track outcomes at the care team level. CMS has proposed to measure quality of care using nationally recognized measures in five key domains: patient experience, care coordination, patient safety, preventive health and at-risk population/frail elderly health. These measures are in alignment with other incentive programs such as the Physician Quality Reporting System and Electronic Health Record Incentives. The Care Solutions’ tools are designed to support the capture of quality and experience of care data through integrated disease and wellness programs while identifying gaps in care associated with ACO quality measures. The Triage Dashboard provides a real-time, aggregate view across patient populations that enable interventions that can prevent unnecessary hospital admissions, prevent adverse events and ensure medication adherence. 4. PROCESS TO PROMOTE COORDINATION OF CAREAn ACO will need to promote, improve and assess integration of care across providers and settings of care. This includes coordinating care between primary care physicians, specialists and acute and post-acute care providers and suppliers of services. At its core, HealthyCircles is designed to provide the infrastructure to meet CMS requirements. These requirements include integrating case managers into the care team, supporting telehealth, enabling remote patient monitoring, sharing data via Health Information Exchanges (HIEs) and providing a complete Transitions of Care program while providing secure messaging across the care team. Patients enrolled in an ACO via HealthyCircles, have full access to their personal data that can be shared through a simple, secure messaging system with non-ACO providers in a bi-directional way.5. PROVIDE PATIENT-CENTERED CAREThe Accountable Care Act defines patient-centered care as care that incorporates the values of transparency, individualization, recognition, respect, dignity and choice in all matters without exception when related to one person’s circumstances and relationships in health care. HealthyCircles is designed to move beyond provider-centric data exchange to patient-centric care.PROVIDING PATIENT-CENTRIC CARE WITH HEALTHYCIRCLESCMS has proposed that an ACO will need to demonstrate that it is meeting the following eight criteria in order to be deemed patient-centric. HealthyCircles provides functionality designed to meet this requirement. • A patient experience of care survey is in place and results inform efforts to improve care delivery. HealthyCircles Engage enables an ACO to launch customized care surveys to gather information about the experience of care at the patient or population level.• Patients will have a role in ACO governance.Patients can become active participants in ACO governance through continued engagement through development of HealthyCircles’ Care Solutions content and integrating community care resources into the care team.• A process for evaluating the needs of diverse patient populations must be in place as well as a model to respond to population health needs. Care Solutions can include patient health risk assessments that can be created and launched. These assessments enable a practice to identify the diverse needs of patients and to enroll them in culturally appropriate health programs that provide information meeting the challenge of health literacy.• A process to identify high-risk individuals and to individualize a care plan for patients including integration of community resources.Based upon patients’ responses to Care Solutions, customized patient care plans can be developed that link patients to the best patient education sources as well as to community organizations that can support their care.• A process in place to exchange summary of care data across transitions of care.When the HealthyCircles Data Exchange Hub (DEH) is integrated into a discharge or referral process, it enables providers to exchange data and efficiently communicate with all members of the care team as well as family members and caregivers across a secure data network. • A process in place for communicating clinical knowledge/evidence-based medicine to patients in a way that is understandable to them.HealthyCircles supports shared-decision making by delivering educational content that is linked to evidence-based guidance. Patients can receive follow-up messages in response to their interactive programs that are delivered in real-time. Patient and caregiver education is delivered to their HealthyCircles’ HIPAA secure Message Center for future reference and for care team access.• Provide written standards to support patient access to their medical record and communication.HealthyCircles supports the ability of patients to access their shared medical record and to communicate directly with members of their unique care team. • An internal processes in place for measuring clinical or service performance of physicians across the practice and show that results informs efforts to improve care and service over time. Institutions using HealthyCircles can assign providers and care teams at the individual patient level. This flexibility provides the opportunity to measure physician performance as well as to measure outcomes at the care team level. THE HEALTHYCIRCLES CONNECTED HEALTH PLATFORMThe HealthyCircles Connected Health Platform provides the tools needed for ACOs to prepare for 2012. More importantly, it empowers true patient-centered care through evidence-based, shared decision-making and integrated care management by physicians, members of the care team, patients and their families. The HealthyCircles Professional Portal connects health care professionals to their patients. This Portal is designed to help the health care professional deliver better patient care and to expand access to their services while optimizing practice efficiency. This Portal speeds the exchange of relevant health information across the continuum of care, allowing convenient access to patient information, enables shared decision-making and offers new models for care delivery.Patients connect to their health care professionals through the HealthyCirclesTM Consumer Portal. This Portal includes a patient’s personal health record and secure messaging through which designated care team members communicate while interactive health programs and services support care. For more

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