Vital Directions for Health and Health Care: Priorities From a National Academy of Medicine Initiative.

Importance: Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost. Objectives: To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity. Evidence Review: Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings. Findings: The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress. Conclusions and Relevance: The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress.

Toward a 21st-century health care system: recommendations for health care reform.

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

Variation in medical care: time for action.

Variations research has broken new ground by moving analysis of Medicare data from the community to the hospital level. The California study of hospitals further illustrates the power of comparing performance to demonstrate the levels of efficiency that can be achieved. WellPoint, replicating the Dartmouth approach with its commercial data, is partnering with medical specialty societies to make data "actionable" and move beyond benchmarking to help providers alter practice patterns. The shared goal is to achieve a material reduction in practice variation throughout health care. Key elements of their partnership include establishing national databases, reducing the administrative burden for pay-for-performance programs and using evidence-based metrics.

When excuses run dry: transforming the U.S. health care system.

Mainstream media have reported on the wide variation in clinical practice documented for years by health service researchers. Raising awareness of the quality and cost implications of clinical variation, however, is not enough to adopt clinical behavior based on the principles of evidence-based medicine (EBM). Preoccupation with EBM's limitations--which can be overcome--and failure to address its misperceptions inhibit transformation to an evidence-based system of care and payment. Three reinforcing efforts are needed: aligning payment with quality; increasing the engagement of consumers; and accelerating investment in and adoption of information technology. Real transformation in health care requires changes in both culture and attitudes.

The leadership journey.

It isn't always easy to change leadership hats or to alter the way you assess a business problem. Under pressure, most executives fall back on the management style or approach that worked in the last crisis they faced. But old approaches rarely work in new and demanding situations. Just ask Leonard Schaeffer, chairman and CEO of WellPoint Health Networks, one of the country's largest and most successful managed-care companies. In this account, he describes how he consciously adopted three very different styles of leadership at critical points during his 30-year career, depending on the business challenges at hand. Schaeffer headed up the U.S. Health Care Finance Administration during the Carter years--and led the charge toward more efficient work practices at that agency. Then he transformed Blue Cross of California from a floundering bureaucracy losing close to $1 million each day into a strong public company, WellPoint. The dire circumstances at Blue Cross had dictated that Schaeffer initially be an autocratic leader, which he considers the managerial equivalent of being an emergency room surgeon--forced to do whatever it takes to save a patient's life. But as the company rebounded, the CEO shed that "any decision is better than no decision" style. He has become a participative, hands-off leader-setting strategies and goals from above but letting WellPoint's line managers and executives figure out how best to achieve those goals. Most recently, Schaeffer has turned into a reformer--a leader who works with one foot outside the company to spur changes in health care and society. There are pitfalls in switching leadership styles, Schaeffer admits, but this flexibility is necessary for realizing corporate- and personal-success.

The new architects of health care reform.

Rising health care costs have been an issue for decades, yet federal-level health care reform hasn't happened. Support for reform, however, has changed. Purchasers fear that health care cost growth is becoming unaffordable. Research on costs and quality is questioning value. International comparisons rank the United States low on important health system performance measures. Yet it is not these factors but the unsustainable costs of Medicare and Medicaid that will narrow the window for health care stakeholders to shape policy. Unless the health care system is effectively reformed, sometime after the 2008 election, budget hawks and national security experts will eventually combine forces to cut health spending, ultimately determining health policy for the nation.