How has healthcare changed in the last 20 years

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With the advent of electronic medical records EMRs , clinical data registries, and other new forms of electronic data, care is becoming rich with information that can reveal patterns of disease mechanisms and markers of risks and benefits.

These data also hold promise for instilling a greater confidence in health care than currently exists for a system that offers widely varying medical practices, with possible consequences for outcomes and definite consequences for costs. In addition, even treatments effective for some may not be beneficial for others and may carry significant risks.

With the cost of health care rising along with its benefits, creating an evidence-based system will be critical to achieving the promise of personalized medicine in which treatments are more effectively targeted to those that benefit, an achievement well worth its cost. Although there has been progress toward this goal, attaining such a system remains a distant prospect. Better disease models and evidence relevant to the treatment of individual patients is lacking, despite publications and news stories that seem to suggest otherwise.

Also, much of the current data are not from traditional randomized controlled trials RCTs , creating a dilemma about the relevance of EBM in clinical practice. Some practitioners believe that if evidence is developed using traditional RCTs, it may not be reflective of the complexities of populations and the delivery settings in real-world practice. For example, even if different practice methods appear to have a similar effect in an overall population, this may not be the case for different subgroups or different types of patients within that population.

The key elements that should inform strategies for change are contained within these pages. As Michael E. Porter notes in Chapter 7 , while simple steps such as price controls or restrictions on access to control costs might seem useful on the surface, they have failed in the past.

Instead, a new vision is needed, marked by effective evidence and targeted treatments that account for the diverse characteristics—findings, histories, validated biomarkers, and preferences—of the various patient groups in this country.

With the complement of secure EMRs, access to these patient and population characteristics will bring relevant evidence to healthcare decision making. This will, in turn, lead to better results and higher value. Clearly, there will be challenges along the way to gather the evidence necessary for the backbone of this type of healthcare system: data must be consistent; low-cost alternatives to RCTs must be agreed upon; electronic systems should be integrated; and sophisticated longitudinal databases, such as provider-led clinical registries, should be supported.

In addition to studying the discrete interventions of particular drugs or particular modalities in treatments, the performance of healthcare systems themselves should be addressed. The variations in care discussed by Elliott S.

Fisher in Chapter 2 must be aligned. Also, costs will increase and value will be compromised if patients receive care from a number of different providers who do not collaborate effectively. To study these delivery system issues in real-world practices, traditional approaches such as RCTs will not be effective. Policy challenges must also be addressed. As George C. Halvorson acknowledges in Chapter 6 , small shifts in the system will not create fundamental change.

Value and outcomes cannot be achieved by micromanaging practices, but rather by providing support for better care at a lower cost.

Rewarding better quality and lower costs will give healthcare professionals the opportunity to deliver quality care and still make ends meet. This includes changing reimbursements to focus on higher value. Making these changes will provide an opportunity for patients to become more involved, and not simply through cost sharing. Many opportunities exist for people with chronic diseases to improve their own health, since most care is actually self-care.

In our traditional insurance system, these individuals do not always have the opportunity to make choices that can save money. However, recent reforms have begun to allow chronically ill patients in this country to control the services they receive. For example, the tiered benefits in Medicare allow beneficiaries to save money by switching to generic drugs—one of the main reasons that Part D in Medicare is less expensive than projected.

There are a number of programs being implemented around this concept of shared savings, in which healthcare professionals working together reap savings when they document better outcomes at a lower cost. However those savings are accomplished—through system redesign, information technology IT , or remote monitoring systems—they are a step toward a bundled reimbursement approach that focuses on the effective outcomes in our healthcare system while promoting better care for everyone in it.

Clearly, the technical and policy challenges of fulfilling the vision of EBM are great. In spite of these challenges, the promise of EBM has put it at the forefront of policy making. The Food and Drug Administration is working to implement major new reforms, including plans for a public-private partnership to support a post-marketing surveillance system to gather data on drug risks and benefits. Also, Congress is considering proposals for a major initiative to support the generation of comparative effectiveness information about healthcare interventions.

In addition to work by the federal government, the practice of EBM will require numerous public- and private-sector strategies and collaborations. Needed are new approaches to the evaluation and adoption of medical best practices, new methods for drawing appropriate conclusions from vastly expanded data resources, and new approaches for using evidence to improve care and reduce health costs.

The process will not be easy, but unlike previous times, there are now widespread calls from healthcare leaders for the reforms needed to develop a system that delivers efficient and effective care. The IOM has the opportunity to catalyze that change. Healthcare reform will be one of the top domestic issues of the political agenda in the next presidential election, making our focus on EBM and the changing nature of health care very timely.

The roles and responsibilities of all healthcare stakeholders are undergoing transformative change and—whether we approach reform as providers, payers, researchers, health product developers, or consumers—there is much to learn from all who are involved in these collaborative discussions about how to contend with the rapid changes in the healthcare system.

Healthcare providers, whether involved in delivering or reimbursing care, face a unique set of challenges as care is increasingly informed by and organized around rapidly evolving evidence. Developing better approaches to reimbursement and other mechanisms that support the delivery of quality care are at the forefront for all providers, and many pilot projects are already under way.

A key consideration, as illustrated throughout this report, is the strong influence of local cultures on practice patterns. They can prevent the infiltration of evidence-based decision making, but they can also lead to great innovation to support the application and development of evidence.

The papers by William W. Stead and George C. Halvorson in Chapters 4 and 6 discuss lessons learned from their efforts to harness electronic health record EHR systems for improved application of evidence in practice and improved capacity for research and discovery, respectively. However, these local solutions may need restructuring to succeed at a national level. There has been considerable advocacy for sharing best practices nationwide, but it may be necessary to set goals and work backwards to align the systems.

For consumers, access to care is a priority but an additional, emerging challenge will be to ensure that incentives for research and care are properly aligned to support care focused on individual patient needs, circumstances, and preferences.

The very nature of patient-physician relationships is also undergoing a rapid change as healthcare data are increasingly captured and made available in various forms through IT.

Patients will be presented with more health information from a variety of sources and, increasingly, they will be pivotal in making decisions about their own health care. As we are reminded by Peter M. Neupert in Chapter 5 , most of health care is self-care and much of the care delivered throughout this country is family-based. Family health managers and the availability of secure personal health records will be critical to informing and providing increasingly individualized patient care.

EBM will also impact researchers. Methodologies to generate evidence are evolving and need to be continually defined and adapted.

EHRs will provide the opportunity to quickly gather large amounts of data from real-world practice and produce evidence in real time, but how these data can be used appropriately and effectively will be a major challenge for researchers and practitioners.

Clearly, developing evidence that draws from and informs real-world care practices is a science, and improved methods for modeling and analyzing work processes and decision management are needed. This may require restructuring of the way we fund research. Federal agencies, such as the National Institutes of Health, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Department of Defense, the Veterans Health Administration, the Centers for Disease Control and Prevention, and others, will be essential components of this dialogue and can demonstrate leadership by partnering across agencies, as well as with others in the private sector.

There is no doubt that the work to transform our healthcare system will be challenging. Many healthcare leaders have been working on improving the system for decades; but we all need to get on with finding a solution now. In the United States the cost of health insurance is rising faster than wages at a rate that is not sustainable, but the quality of care—measured in outcomes, safety, and service—is much lower than it should be. Especially in comparison to other countries, the value of medical care in the United States is low but even among individual states of the United States the variability in the value of health care delivered is dramatic.

Only 10 percent of the states provide high-value care on average, and the value of care in the United States on a whole is well below what should be expected. Given the current approach to health care, however, these shortfalls are not surprising. Across the healthcare system, competition and rewards are not based on value, and there are scant incentives for patients to seek—or for professionals to provide—high-quality, cost-effective health care.

In reality there is no true healthcare system. There never has been a conscientious attempt to design and maintain a system that would create value. We now have an opportunity to take the steps to develop a vision, create a strategy, and specify goals for a true system of health care in the United States. Yet what should a healthcare system do? In sum, a healthcare system should improve the quality of life and aim to keep people as well as possible, while ensuring that healthcare expenditures are affordable for both individuals and the nation.

In essence, a reformed healthcare system should provide individuals with high-value health and health care. As outlined in Chapters 2 and 3 , these forces include rising and unsustainable costs, wide variations in the quality and cost of health care delivered across the United States, and the complexity of care introduced by the emerging insights from genetic research and the diversity of new health products.

Many of the issues discussed throughout this publication are important for moving forward with needed healthcare system reform, but my focus is on key considerations for providers and, to some degree, patients. Most pressing in this respect is an improved understanding of what constitutes good evidence of effective care and outcomes.

For a profession that adopted the scientific method about a century ago, there is alarmingly little evidence for the effectiveness of much of what is taught and practiced today.

To get to an evidence-based, value-driven health system we have to align all of our professional educational programs to teach new systems and capabilities. Introduction to key concepts in EBM should begin, at the very least, at the college level.

In addition, the dissemination and incorporation of new knowledge into practice must be accelerated so that it does not require a decade or more for the average provider to adopt new knowledge and skills.

As more and better evidence is developed, effective processes and IT systems are needed to ensure that healthcare practice utilizes best evidence. These systems should also have feedback loops to continuously improve on the evidence. Systems must be interoperable and scalable and must also incorporate the patient into the decision-making and care provision processes. To be effective, systems must include the proper rewards, incentives, and financing for providers, as well as the means to pay for required processes and IT systems and innovations.

The general public will need education and support to be able to use the copious medical information becoming available, as well as to gain an appreciation for information that is backed by solid evidence. Practitioners need to work with the public to help ensure that we find the right health-care solutions for individual patients. The complexity of clinical evidence is daunting even for experienced, trained professionals who diagnose and treat disease; but it is far more challenging to the non-expert.

Reducing this complexity is key to empowering patients—not only as better informed consumers of health care, but also as active partners in improving health outcomes. In addition, the right kinds of professional support should be made available to patients, whether through health coaches or other sorts of new professionals who can support and educate patients on the best evidence-based processes for health care and healing.

It is clear that we are still at a rudimentary level of conceptualization and implementation of an evidence-based, value-driven healthcare system and that we still have a long way to go. Finding ways in which patients and providers can be proactive in catalyzing and implementing the needed changes is essential.

A learning healthcare system is defined as one in which the usual and customary activities associated with the production, distribution, utilization, and financing of healthcare services result in the simultaneous development and capture of data that are essential to the monitoring and evaluation of health care delivered. A wide variety of information is contained in these data including, but not necessarily limited to, patient characteristics e. Through efficient organization and analysis, and provision of findings at the point of care, these data are a rich resource for informed decision making.

Two general categories of decisions require an expanded evidence base. The first category includes the use of drugs, devices, and procedures. The second category concerns the management of care itself, including the organization of care, IT, types and effectiveness of providers, and clinical pathways.

Both categories require not only effectiveness information but also comparative effectiveness information, including cost or value. As emphasized in Chapter 2 , attention is needed on the evaluation of drugs, devices, and procedures, as well as on systems of care and the healthcare professionals that are involved in the provision of the care.

One of the major strategies proposed to hasten development of the required evidence base includes migration away from traditional reliance on RCTs and inclusion of a variety of other approaches and data sources. Is the question really black and white, or are there strategies to enhance the types of data being used to build the evidence while at the same time hedging against the pitfalls of lower quality and less reliability?

The papers featured in Chapter 6 offer insights on the opportunities presented by EHRs and clinical registries, as well as some of the challenges of using these data to inform the development of effective healthcare interventions.

Public policy has a major role in shaping and driving the development of an improved healthcare system. The following chapters illustrate the potential of EBM to transform health care, and important policy considerations are detailed in Chapter 7. However, it is vital to keep in mind the substantial challenges inherent to the processes of policy making. In short, these processes are badly in need of repair because they have been corrupted by the corrosive impact of election campaign finance monies.

Today, many members of Congress are in a permanent state of running their campaigns for reelection. Presidential politics has become a billion-dollar enterprise, and one has to wonder what kind of impact that sort of money has on public policy.

Is the public being served or sacrificed through this process? As suggested by the opening comments, the IOM Annual Meeting highlighted both the shortfalls of the current system, as well as the tremendous potential for an evidence-driven and value-based health care. The meeting was structured to provide an overview of the key challenges and opportunities for progress and improvement. Session 1 Chapters 2 and 3 reviewed the need for better medical evidence, characterizing not only the waste and inefficiency endemic to health care and the unsustainable trajectory of healthcare expenditures, but also the challenges presented by medical technologies of increased diversity and complexity and an increasingly sophisticated understanding of genetic contributions to disease.

Challenges faced by patients and providers in using evidence to better guide healthcare decisions were reviewed in Session 2 Chapters 4 and 5. Also considered in these chapters were ways that advances in IT affect opportunities for improved access to health information and decision support. IT will also help transform how evidence is developed.

The potential of EHRs, clinical data registries, and new research methods to speed the generation of evidence, as well as drive innovation and the development of tailored therapies were discussed in Session 3 Chapter 6. The last session of the day was devoted to discussing how policy changes might facilitate better stakeholder alignment on how health care is structured and incentivized to deliver high-value health care.

During the course of the meeting, a number of common themes were identified Box The Changing Nature of Health Care. You might also consider going the telemedicine route, which entails talking to a doctor online, rather than going to an in-person appointment. Telemedicine usage also gained momentumduring the coronavirus pandemic. Overall, turning to telehealth may not only reduce your healthcare costs - it could save you time and keep you out of the waiting room.

Ask If All Tests Are Necessary You may think that doctor-ordered tests are standard protocol, but those tests could get expensive fast. Be sure to ask your doctor if all diagnostic tests are necessary for your health. Don't be afraid to ask your doctor if all diagnostic tests are necessary for your health. Here are some questions to get the conversation started. Why is the test being done? What steps does the test involve? How long will it take to get the results?

What will the test cost? Request Outpatient Services When Possible Did you know that some inpatient procedures can be performed on an outpatient basis?

Often, doctors choose to have a procedure performed on an inpatient basis, simply for the convenience of the patient and the medical staff. Many procedures do require a medically supervised period of recovery, but not all of them. There's nothing wrong with asking your doctor if a procedure can be performed in an outpatient clinic rather than at the hospital. If so, the savings can be significant. Choose Your Doctors Wisely Just because a physician or facility accepts your health insurance or Medicare plan doesn't mean that your costs will be controlled.

If you're on Medicare, consider these two steps: First, check if the provider accepts assignment. This means that the provider has agreed to accept the Medicare-approved amount as full payment for services. If your provider doesn't accept assignment, then your out-of-pocket costs may be higher. Second, choose the right doctor for you. The ideal provider has specialized experience with those age 65 and over, which can save you repeated visits to the doctor.

One way to shop around for doctors and specialists is through the physician compare feature on Medicare. You can use this tool to compare providers in your area, or you may opt to discuss the topic with a licensed insurance agent. In general, researching and shopping around for the right healthcare provider could save you money over time. Use Your Medicare Benefits It may sound contradictory, but going to the doctor can ultimately lower your healthcare costs.

Most insurance plans, including Medicare Advantage, come with certain wellness benefits. Getting regular physicals and patient-specific tests can uncover minor health problems before they become major ones. Let's say a man gets a routine PSA blood test done, which reveals the possibility of low-grade prostate cancer.

Early intervention makes the treatment cost far less early on, resulting in fewer trips to the doctor and fewer copays. In other words: lower cost. You Can Save On Healthcare Costs Bottom line: Don't be afraid to do your research, ask the right questions, and incorporate healthy habits to decrease healthcare costs.

You can also find more tips to avoid medical debt in this article. But the bankruptcy rate across America remains high - despite how the ACA has contributed to fewer bankruptcies across the country. Roughly , people declare bankruptcy each year, with Take Susan, a young mother, as an example: Susan had to have a Cesarean section when giving birth to her second child. During the procedure, she and the baby suffered an amniotic fluid embolism, which caused her to need multiple plasma and platelet transfusions and a full hysterectomy.

While both mother and child survived, the family finances did not. Under the unforeseen circumstances, Susan had to stay longer than expected. And the final hospital bill caused Susan and her husband to file bankruptcy. Their experience is all too common. People enter the hospital for "routine" procedures and sometimes leave under crushing debt. And while hospitals give lifesaving care to patients, you may find many items on your bill that'll drive up the total cost.

So how can people protect themselves against high — often inflated — hospital costs? How hospital charges add up quickly Hospitals are a business. Patients are charged for everything including incidental expenses. And those tiny alcohol swabs can add up fast. Other ways patients may see higher costs on their hospital bills: Mistakes in billing.

As with any other service, mistakes happen. But it seems that billing errors at hospitals are commonplace. Network nuances. The hospital you chose might be in-network, but some of the providers and associated procedures like radiology techs, lab services, and specialists such as anesthesiologists may not be.

If these are used during your stay, you may have to pay for these services out of pocket. Unnecessary tests. Doctors often ask for tests which are not deemed necessary by the insurance company. How a hospital indemnity plan can offset certain costs Many people are finding that hospital indemnity plans can offset certain costs associated with their hospital stays that major medical health insurance does not cover.

Most contain some form of patient share as a coinsurance percentage or a copay amount. And there are deductibles and items which fall outside of the in-network coverage. In other words, having a single health insurance policy is sometimes not enough to protect you from the high costs of a hospital stay. What is a hospital indemnity plan? A hospital indemnity plan is a form of insurance developed that helps you cover additional costs not included in a major medical plan. Unlike major medical, which pays the provider, hospital indemnity plans will pay the person covered.

The way it works is an insurance company can pay cash directly to you or you can have the hospital submit a claim , so you can use it toward out-of-pocket expenses your health insurance might not cover. This allows you to use the funds as you see fit, whether it's for deductibles, travel, or lost income while you're in the hospital.

Simply put: The owner of a hospital indemnity policy is in control of the funds — not the provider. There are many other terms often used for hospital indemnity plans, which include: Supplemental hospitalization Hospital insurance Hospital cash plans Healthcare indemnity Medical indemnity Health benefit indemnity Fixed indemnity health insurance Indemnity medical plan Health benefit indemnity insurance How does an indemnity plan work?

When you buy a hospital indemnity plan, your insurance company will pay you a fixed amount to pay for your medical bills or use the money to supplement income, child care, or any expenses you faced while hurt or sick. Your insurer will then pay you a set amount based on a predetermined rate listed in your policy. You'll still want to review your hospital bill to make sure you're not being overcharged - even with a hospital indemnity plan.

Doing this will put more money in your pocket for other costs related to the hospital stay. Is a hospital indemnity plan right for you? A hospital indemnity plan can work for most people. And the reality is: Not many Americans can afford that expense. So hospital indemnity plans can go a long way toward protecting your finances. To help, here are some tips to reduce costly hospital bills.

Watch for billing errors. Ask your provider for the medical billing codes of the procedures you receive so you can make a note of them. Then, request an itemized bill and compare the billing costs after you've been treated. You'll bill probably isn't correct if you see a procedure performed on Thursday, but you checked out on Wednesday.

Don't be afraid to challenge any charge that might be an error. Request only in-network providers. Be sure to let hospital staff know that you only want in-network providers. Most will honor this, if they can. Some states even have laws requiring them to honor your request. Watch for unnecessary tests. Ask if each test is necessary and covered.

Your doctor may have a good reason for requesting the test, but it's up to you to make an informed choice.

Shop around. Call hospitals in your area and ask for their rates if you have a planned procedure. Choose the right facility. Consider an urgent care or clinic before going to the hospital. If it's an emergency situation, your best bet is to always call But if not, choosing the right facility might lower your out-of-pocket costs. Extending your hospital stay even one day longer can add hundreds or even thousands to your bill.

While it's at the doctor's discretion, it's OK to ask if another night is needed. The bottom line is that billing mistakes happen: Don't be afraid to question charges on your hospital bill. Be sure to request an itemized billing statement so you can review all charges.

And if you're calling the hospital or a customer service line, be sure to get reference numbers and names of the people you speak with. That way, the call can be tracked and the issue can be potentially corrected. More on hospital indemnity plans A good hospital indemnity plan can provide you with protection from the high - often hidden - costs of hospitalization. And there are many hospital indemnity plans on the market today, so knowing which is right for you can be difficult.

Our licensed insurance agents are here to talk through your needs and help you find the best hospital indemnity plan to ensure you understand how each will work for you. Save time and money by finding and comparing hospital indemnity plans in your area. You can also click here to get more tips on how to reduce healthcare costs.

Find Health Plans. In The News. Learning center. Find a Medicare plan. Some key provisions include: The creation of a health insurance marketplace in every state to provide consumers with a place to purchase health insurance.

Income-based subsidies, including premium tax credits and cost-sharing reductions, for those who purchase individual coverage through the health insurance marketplace i. Guaranteed issue and renewal of policies. Short-term health insurance kept its stride Short-term health insurance is temporary insurance that provides coverage in certain medical situations like an unexpected accident or illness.

Obama limits short-term policies Concerned that short-term health insurance was impacting ACA enrollment, the Obama administration created regulations that limited their availability. Trump expands short-term policies In , the Trump administration lifted Obama-era limits. High-deductible health plans grew in popularity High-deductible health plans, called HDHPs, were introduced in the early s and were considered "mainstream plans" by Here are some interesting facts: HDHP enrollment jumped from 10 million people to Healthcare spending continues to climb If it seems like your healthcare costs increased throughout the past decade, it probably did.

An opioid epidemic devastates our nation The opioid epidemic might be the most daunting and complex public health crisis of our time. Here are some of the most shocking reports: Opioid overdoses accounted for more than 42, deaths and increased to 47, people in By , more than 90 Americans per day were dying from opioid overdose.

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