Healthcare Policy

Health policy is the decisions, plans, and actions that are undertaken to achieve specific healthcare goals within a society. It involves the creation and implementation of laws, rules, and regulations for managing nation’s healthcare system. The World Health Organization in its definition states that, “healthcare policy details a vision for the future; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people.” What is key to all this is the understanding that these policies not only affect the cost of care citizens must pay, but also their access to care and the quality of care received, which can influence their overall health.

There are many categories of health policies, including global health policy, public health policy, mental health policy, health care services policy, insurance policy, personal healthcare policy, pharmaceutical policy, and policies related to public health such as vaccination policy, tobacco control policy

Beginning in the mid-20th century the federal government took an increasing role in regulating the healthcare industry in the US. Some major policy legislations enacted included:

  • Social Security Amendments of 1965: which established Medicare and Medicaid
  • Health Maintenance Organization Act of 1973: which promoted prepaid group practice service plans known as health maintenance organizations (HMOs) as an alternative to fee-for-service plans
  • Consolidated Omnibus Budget Reconciliation Act of 1985: which allowed employees to continue healthcare coverage if they would otherwise lose it (due to job loss, medical leave, etc.)
  • Health Insurance Portability and Accountability Act of 1996: required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
  • Patient Protection and Affordable Care Act of 2010, known as Obamacare: 3 main objectives: (1) to reform the private insurance market—especially for individuals and small-group purchasers, (2) to expand Medicaid to the working poor with income up to 133% of the federal poverty level, and (3) to change the way that medical decisions are made.

 There is one major legislation that has been floated around since the early 1900’s, that is the call for a national health insurance program; however as of 2021 no such measure has been adopted in the United State. And with the partisan divide in congress enactment of any such legislation seems more like an urban myth than a reality.

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Medicare Advantage (MA)

Is Medicare Advantage the future for Medicare beneficiaries?

In 2020,  

  • 40% of Medicare beneficiaries were covered under Medicare Advantage plans.
  • About 99% will have access to at least one Medicare Advantage plan  

What is Medicare Advantage

Medicare Advantage (Medicare Part C or MA) is a type of health insurance plan that provides Medicare benefits through a private-sector health insurer; Here, the Medicare beneficiary pays a monthly premium (usually much lower than original Medicare) to a private insurance company and in return:

  • Receives coverage for inpatient hospital (“Part A”)
  • Coverage for outpatient (“Part B”) services.
  • The plan also includes prescription drug (“Part D”) coverage.
  • And a host of ancillary “fringe” additional benefits, such as dental/vision coverage or gym memberships.

By contrast, in traditional Medicare, the Medicare beneficiary pays a monthly premium to the federal government and receives coverage for Part A and Part B services, but must purchase other coverage (e.g., for prescription drugs) separately

Advantages and Disadvantages

  • Medicare Advantage plans are managed care plans, usually with limited provider networks, by contrast mostly all physicians and hospitals accept original Medicare; thus, giving beneficiaries better access
  • Both charge a premium for Part B benefits, and about 40% of Medicare Advantage enrollees with prescription drug benefits pay an additional premium.
  • Medicare Advantage plans include an annual out-of-pocket spending limit, while Original Medicare does not and is usually supplemented with a “Medigap” plan
  • Medicare Advantage plans promotes coordinated medical care. The healthcare providers (usually collocated or co-employed) actively communicate to coordinate your care between different types of healthcare services and medical specialties. This ensures you have a healthcare team and helps avoid unnecessary expense and issues like medication interactions

Original Medicare still operates in the Fee for Service world where the rendering provider/organization is reimbursed for each service performed (up to an allowed amount). Conversely the Medicare program pays Medicare Advantage insurers a monthly lump sum for each enrollee (capitation-PMPM) to cover the cost of carrying their beneficiaries, the plan is assessed (yearly) on how well they manage the assigned population -what value they have provided.

Research has consistently shown that Medicare Advantage (MA) outperforms traditional Medicare on several quality measures such as preventive screenings and avoiding hospitalizations. This can be attributed in part to the payment arrangement these plans have with CMS which includes risk-adjusted capitation payments and strong value-based care performance incentives to “enable plans to offer care management interventions that help meet the complex care needs of vulnerable beneficiaries in ways that achieve positive health outcomes.”


The choice is based entirely on your personal situation. When a client is comparing which option is better, (s)he must consider:

  • medical situation/status
  • monthly and yearly budget
  • preference for providers
  • other lifestyle factors that can impact care and costs
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Patient Centered Medical Home (PCMH)

Patient Centered medical Home is a team-based approach to health care that puts the patient at the forefront of care; led by a primary health care provider, the model provides comprehensive and continuous medical care to patients in an effort of obtaining maximal health outcomes. The term was first introduced by the American Academy of Pediatrics in 1967; here the home was proposed as a central source for all the medical information about a child. It has since evolved and in 2007, a coalition of the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association— released the Joint Principles of the Patient-Centered Medical Home. The principles include (at the clinic level):

  • Personal physician: each patient has an ongoing relationship with a personal physician  
  • Physician directed medical practice: the personal physician leads a team of individuals who collectively take responsibility for the patient’s care.
  • Whole person orientation: the personal physician/team is responsible for providing for all the patient’s health care  
  • Care is coordinated and/or integrated Care is coordinated and/or integrated among complex health care systems,  
  • Quality and safety
    • Partnerships between the patient, physicians, and their family  
    • decision-making rooted in evidence-based medicine  
    • engagement in performance measurements  
    • Patients are involved in decision-making  
    • Utilization of informational technology to ensure optimal patient care,   
    • Enhanced access to care is available   

  Research has shown that Patient Centered Medical Home (PCMH) practices improve quality and the patient experience, and increase staff satisfaction—while reducing health care costs; thus satisfying the quadruple aim of medicine. Practices that earn recognition have made a commitment to continuous quality improvement and a patient-centered approach to care.

The US Healthcare (spending and outcomes) part 2

The USA spends more on healthcare than other country on earth, both in actual dollar amount and also as a percentage of its GDP. Yet, quality indicators have the USA in the cellar position (among the world’s industrialized countries) in many of the outcome metrics. This includes a lower life expectancy rate, a higher suicide rates, and a comparable higher chronic disease burden.

The salient question is then, why for all its spending does the USA find itself in this unenviable position?

What research and analysis have shown is that the USA has the highest rates of avoidable morbidity and mortality mainly because of its population not receiving timely, high-quality care. And the reason for his delay is in large part attributed to cost; the cost of healthcare in the US and its contribution in denying access to many of our citizens. In order to alleviate this conundrum, the USA must find approaches that aim to lower health care prices.

Another important factor is the urgent need for addressing risk factors and the management of chronic conditions. Here, the suggestion is to promote and strengthen access to care and primary care systems. Easier said than done since there are affordability and availability barriers in accessing physician visits, treatments and tests   

Finally, noted is the idea of overtreatment or low-value care, which includes an overabundance of tests, treatments, and procedures, that provides little or no benefit (prevalent in the fee for service system -FFS) is common in the US and is a major contributor to the phenomenal cost. The suggestion is the switch to value-based care system which promotes conversations around evidence-based care between physicians and their patients to help evaluate which tests and treatments are truly necessary; providing the most cost-efficient quality care.

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The US Healthcare (spending and outcomes) part 1

In 2019, the U.S. spent 17.7 percent of its gross domestic product (GDP) on health care ($3.8 trillion or $11,582 per person), nearly twice as much as the average eleven G10 industrialized countries. As a comparison, New Zealand and Australia devote only 9.3 percent, approximately half as much as the U.S. spends.

What are the outcomes, based on quality metrics? According to The Commonwealth Fund (The Commonwealth Fund, 2020):

  • The U.S. spends more on health care as a share of the economy — nearly twice as much as the average industrialized country — yet has the lowest life expectancy and highest suicide rates among the G10 nations.
  • The U.S. has the highest chronic disease burden and an obesity rate that is two times higher than the G10 average.
  • Americans had fewer physician visits than peers in most countries, which may be related to a low supply of physicians in the U.S.
  • Americans use some expensive technologies, such as MRIs, and specialized procedures, such as hip replacements, more often than our peers.
  • The U.S. outperforms its peers in terms of preventive measures — it has the one of the highest rates of breast cancer screening among women ages 50 to 69 and the second-highest rate (after the U.K.) of flu vaccinations among people age 65 and older.
  • Compared to peer nations, the U.S. has among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.

What are the takeaways:

While the United States spends more on health care than any other country, it is not achieving comparable performance. The analysis shows health outcomes, including low life expectancy and high suicide rates, compared to our peer nations. Efforts to rein in costs, improve affordability and access to needed care, coupled with greater efforts to address risk factors, are required to alleviate the problem.

We will look at a more in-depth analysis of this pressing problem in the next blog posting.


The Commonwealth Fund. (2020, January 30). Retrieved from U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?:

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Telehealth — sometimes called telemedicine — is the use of electronic information and telecommunication technologies to access health care services remotely and manage your health care. “Modern” informational technology meets classic medicine; all you need is a phone or a device with internet access you are all set, able to get medical care or services through the telehealth platform. Here you are able to:

  • Communicate with your provider live in real time
  • Send and receive messages from your provider using chat messaging, email, secure messaging, and secure file exchange.
  • Use remote patient monitoring – allowing your provider to evaluate you at home

What types of care are suited for telehealth?

Telehealth is not a perfect fit for everyone or every medical condition. A consultation with your provider is advised to let you know whether telehealth is right for your health needs. Having said that, a telehealth visit is designed to managed a variety of health care needs. Services like medication management and online counseling are particularly suited to telehealth as consistent and regular visits improve outcomes.

Benefits of telehealth

Although virtual visits may not be as common as traditional in person doctor’s appointments, there are many benefits to this visit type; these include:

  • Limiting physical contact; more so during this COVID-19 era
  • Visiting virtually can address health issues for patients who are remote
  • Make services more convenient for people with limited mobility, time or transportation options.
  • Cuts down on commuting; travel in bad weather and also addresses a host of social concerns (including time off from work, need for child care e.t.c.)
  • Using virtual health care tools can improve access to healthcare; may shorten wait times to see a provider and expand the range of access to specialists  
  • Improve communication and coordination of care among members of a health care team and a patient.
  • Provide support for self-management of health care.
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Quality metrics in Health care

What are Quality Measures?

According to CMS, “Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care.”

In other words, they set the goals we use to effectively tack and manage population health.

What do they measure?

The various measures look at a different aspect of the system and together provides a comprehensive view of the quality of healthcare

. Quality measures includes:

  • Health outcomes
  • Clinical processes
  • Patient safety
  • Efficient use of healthcare resources
  • Care coordination
  • Patient engagement in their own care
  • Patient perceptions of their care
  • Population and public health

Why Use Them?

Measures inform us about how the health care system is performing. Measures help identify weaknesses, prioritize opportunities; Measures drive improvement. Measures are becoming increasingly important relative to payment as the U.S. health care system shifts away from traditional fee-for-service toward payment focused on the value of care.

How are they collected or reported?

Depending on the measure, data can be collected from different sources, including medical records, patient surveys, and administrative databases used to pay bills or to manage care. They are then analyzed internally for performance improvement and/or also reported to the various regulatory authorities (CMS, NCQA ETC) via claims- direct link or via registry, for benchmarking purposes.

Universal Healthcare (part 2)

The question is why does the world most powerful and richest nation on earth – the beacon for democracy and capitalism does not have a universal healthcare system in place-

Looking at the 7 most developed nations (G7) on earth, the USA is the only country where its citizens can (and do) go bankrupt secondary to having medical condition- and having insurance does not guarantee protection from this catastrophe.

Why is there no Universal Healthcare?

According to an article from the conversation in 2016, there are three main reasons:

No. 1: We don’t want it

One key reason is America’s unique culture. Americans very individualistic with an entrepreneurial spirit. There is a general belief that the government should play a limited role in society. The concept of universal health coverage is very opposite of the belief in individualism and limited government, so not surprising that it has never been enacted

No. 2: Interest groups don’t want it

The insurance industry is a key player in this process, spending hundreds of millions of dollars to help shape the industry, keeping private insurers versus the government, as the key player in American health care.  

 No. 3: Entitlement programs are hard in general to enact

A third reason America lacks universal health coverage is that America’s political institutions make it difficult for massive entitlement programs to be enacted. Partisan politics make passing this legislation vey unlikely (well at least currently)

So, for the present moment, it would appear that universal healthcare is off the table in the US – commercial insurance continues to be the dominant player.

Universal healthcare (part 1)

With all the partisan bickering about the ACA (Obamacare) and the recent Supreme Court ruling, this week blog forms a two-part series on Universal Healthcare

What is Universal healthcare

Universal health care is a system that provides quality medical services to all citizens; all residents of a particular country are assured access to health care. It is offered to everyone regardless of their ability to pay.   

Thirty-two countries in the world have adopted some sort of a Universal Health Care system. The U.S.  being the only wealthy, industrialized nation without universal health care.

There are three broad universal health care models:

  1. single payer,
  2. mandatory insurance, and
  3. national health insurance

Single-Payer Model (the Beveridge Model)

Exampled by the UK and Cuba

Here, the government provides health care paid for with revenue from income taxes. Both services and providers are government-owned and employed; Every citizen has the same access to care. Interestingly, the United States offers this model to veterans and military personnel with the Department of Veterans Affairs and the armed forces

Social Health Insurance Model (Bismarck model)

Exampled by the Germany and France

Under this model all citizens are required to buy insurance usually through their employers. Employers deduct taxes from employee payroll to cover the costs, and the taxes go into a government-run health insurance fund that covers everyone. The Obamacare is based on this model.

National Health Insurance

Exampled by the Canada and Taiwan

The national health insurance model uses public insurance to pay for private-practice care. Every citizen pays into the national insurance plan. Administrative costs are lower because there is one insurance company and the government having a lot of leverage to force medical costs down. The U.S. Medicare, Medicaid, and TRICARE systems are based on a national health insurance approach

 The United States (generally) has a mixture of government-run and private insurance; Data has shown about 68% of Americans have private health insurance, mostly from their employers. With another 34.1% having government coverage (Medicaid, Medicare, CHIP, and the VA). 8% of the population have no coverage at all, of note almost 20% of the nonelderly population lacks health insurance at any given time.

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