我觉得很好玩的还有这段困境：
Vermont faces a $150 million budget shortfall. Employers argue that health care costs jeopardize their businesses' financial viability, while families struggle to pay out-of-pocket health care costs. Vermont businesses and workers are unwilling to spend more for health care. On the other hand, Vermonters are also largely unwilling to reduce their level of benefits. Our analysis found that, on average, Vermonters have rich insurance benefits approaching the ACA's "platinum" standard. Similarly, physicians and hospitals are unwilling to accept reductions in their net incomes.
Hsiao向Vermont州设计的医疗系统(包括delivery和financing system)—State-based, Single Payer Health Care：
We found that the system capable of producing the greatest potential savings and achieving universal coverage was a single-payer system — one insurance fund that covers everyone with a standard benefit package, paying uniform rates to all providers through a single payment mechanism and claims-processing system. Our analysis showed that Vermont could quickly save almost 8% in health care expenditures through administrative simplification and consolidation, plus another 5% by reducing fraud and abuse
We recommended that the single payer be a public–private partnership. An independent board with representation from both the major health care payers (employers, the state, and workers) and the major beneficiaries and recipients of payment (providers and consumers) would negotiate updates to the benefit package and payment rates. We also proposed contracting out claims administration through a competitive bid to create incentives to develop more efficient systems.
This system reduces the rate of cost increases over time by insulating major decisions about health care spending from politics, as well as by paying providers through capitation rather than fee for service, promoting delivery-system integration, and reducing the practice of defensive medicine by implementing a no-fault medical malpractice system. All told, we estimated that Vermont could save 25% in health care expenditures over 10 years (estimated savings for the first 5 years are shown in the table).
Hsiao的研究团队对其方案进行了"微观模拟"和"宏观模型"分析以估计single-payer系统的影响：
We used two economic models to estimate the impact of the proposed system. We fed estimated savings and costs under the single-payer system into a MicroSimulation Model, developed by the MIT's Jonathan Gruber, which simulated the likely responses to the ACA by employers and low-income workers and estimated the amount of state and federal spending under the law, as well as computing the payroll contribution rates necessary to finance our plan. We then fed those results into a macroeconomic model developed by Regional Economic Models to estimate the effects on jobs and the gross state product that would result from additional spending for health care when more people were covered and the increase in household income and consumption when insurance premiums decreased with a single-payer plan. The models predicted that, as compared with implementing the ACA, the single-payer system would result in lower spending by employers, the state, and households and in the creation of more jobs in Vermont. For example, without single-payer reforms, we predict that employers would pay 12% of their payrolls in health insurance premiums in the first year, with further increases to follow.
Vermont州的改革进展和后续预期(包括阻力和支持)：
The governor has already introduced legislation establishing the first building blocks of a single-payer system: payment reform, the creation of the independent board, and the mandate to build Vermont's health insurance exchange as a platform for a single-payer infrastructure. Legislation establishing universal coverage and its financing will follow, when the state can obtain waivers from Medicare's and Medicaid's provider-payment rules and the ACA's individual mandate and subsidy rules. Innovative state reforms are being encouraged, as illustrated by Obama's support for the Wyden–Brown bill, which would grant waivers from ACA requirements in 2014 if states can meet the ACA's goals. The Vermont single-payer plan certainly can.
Source：http://healthpolicyandreform.nejm.org/?p=13939&query=TOC
荷兰的改革(Bundled-Payment and Care Group)vs美国(ACO. etc)
荷兰—什么是care group和bundled-payment？
Under this system, insurers pay a single fee to a principal contracting entity — the "care group" — to cover a full range of chronic disease (diabetes, COPD, or vascular disease) care services for a fixed period. A care group is a newly created actor in the health care system, consisting of a legal entity formed by multiple health care providers, who are often exclusively general practitioners (GPs). The care group assumes both clinical and financial responsibility for all assigned patients in the diabetes care program. For the various components of diabetes care, the care group either delivers services itself or subcontracts with other care providers.
The bundled-payment approach supersedes traditional health care purchasing for the condition and divides the market into two segments — one in which health insurance companies contract care from care groups and one in which care groups contract services from individual providers, be they GPs, specialists, dietitians, or laboratories. The price for the bundle of services is freely negotiated by insurers and care groups, and the fees for the subcontracted care providers are similarly freely negotiated by the care group and providers.
荷兰vs美国
The aims of these care groups are similar to those of ACOs, as currently conceived in the United States, but there are differences in some essential features. For example, care groups are dominated by GPs, whereas ACOs may comprise a wide range of providers — at least primary care physicians, specialists, and one or more hospitals. In addition, patients are to be assigned to ACOs on the basis of their patterns of service use, whereas patients are assigned to a care group on the basis of their disease (beginning with diabetes). In addition, the care group bears the full financial risk for the cost of care, whereas ACOs won't bear the risk of higher-than-expected costs.
Both concepts are relatively new: the ACO concept has not been fully tested, and the Medicare ACO program doesn't begin until January 2012; care groups were launched on an experimental basis in 2007, focused only on type 2 diabetes. The implementation process for the bundled-payment system is under evaluation, and data from electronic health records of 10 care groups, extensive interviews with stakeholders, and patient questionnaires are being used to assess the satisfaction of all stakeholders and the quality of delivered care.
Source：http://healthpolicyandreform.nejm.org/?p=13943&query=TOC
