Dataset Information

What is Single-Payer Health Care? A Review of Definitions and Proposals in the U.S.

ABSTRACT:

Background

Single-payer systems have been proposed as a health care reform alternative in the United States. However, there is no consensus on the definition of single-payer. Most definitions characterize single-payer as one entity that collects funds and pays for health care on behalf on an entire population. Increased flexibility for state health care reform may provide opportunities for state-based single-payer systems to be considered.

Objective

To explore the concept of single-payer and to describe the contents of single-payer health care proposals.

Design

We compared single-payer definitions and proposals. We coded the proposal text for provisions that would change how the health care system functions and could impact health care access, quality, and cost.

Main measures

The share of proposals that include changes to the financing, pooling, purchasing, and delivery of health care; and possible impact on access, quality, and costs.

Key results

We identified 25 proposals for national or state single-payer plans from journal and legislative databases. The proposals typically call for wide-ranging reform; nearly all include changes across the financing, pooling, purchasing, and delivery of health care services. Many provisions aiming to improve access, quality, and cost containment are also included, but the proposals vary in how they plan to achieve these improvements. Common provisions are related to comprehensive benefits, patient choice of providers, little or no cost sharing, the role of private insurance, provider guidelines and standards, periodic reviews of the benefits package, electronic medical records and billing, prescription drug formulary, global budgets, administrative cost thresholds, payment reform and studies, and the authority to implement cost-containment strategies.

Conclusions

Single-payer systems are heterogeneous. Acknowledgment of what is considered as single-payer and the characteristics that are variable is important for nuanced policy discussions on specific reform proposals.

SUBMITTER: Liu JL

PROVIDER: S-EPMC5481251 | biostudies-literature | 2017 Jul

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

What is Single-Payer Health Care? A Review of Definitions and Proposals in the U.S.

Liu Jodi L JL Brook Robert H RH

Journal of general internal medicine 20170510 7

<h4>Background</h4>Single-payer systems have been proposed as a health care reform alternative in the United States. However, there is no consensus on the definition of single-payer. Most definitions characterize single-payer as one entity that collects funds and pays for health care on behalf on an entire population. Increased flexibility for state health care reform may provide opportunities for state-based single-payer systems to be considered.<h4>Objective</h4>To explore the concept of singl ...[more]

PMID: 28493177

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Project description:ObjectiveExcess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them.Data sourcesLiterature review and national utilization and expenditure data.Study designWe developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing.Data extractionFor several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters.Principal findingsOur model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies.ConclusionAlthough moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system.

Project description:Importance:US health care spending has continued to increase and now accounts for 18% of the US economy, although little is known about how spending on each health condition varies by payer, and how these amounts have changed over time. Objective:To estimate US spending on health care according to 3 types of payers (public insurance [including Medicare, Medicaid, and other government programs], private insurance, or out-of-pocket payments) and by health condition, age group, sex, and type of care for 1996 through 2016. Design and Setting:Government budgets, insurance claims, facility records, household surveys, and official US records from 1996 through 2016 were collected to estimate spending for 154 health conditions. Spending growth rates (standardized by population size and age group) were calculated for each type of payer and health condition. Exposures:Ambulatory care, inpatient care, nursing care facility stay, emergency department care, dental care, and purchase of prescribed pharmaceuticals in a retail setting. Main Outcomes and Measures:National spending estimates stratified by health condition, age group, sex, type of care, and type of payer and modeled for each year from 1996 through 2016. Results:Total health care spending increased from an estimated $1.4 trillion in 1996 (13.3% of gross domestic product [GDP]; $5259 per person) to an estimated $3.1 trillion in 2016 (17.9% of GDP; $9655 per person); 85.2% of that spending was included in this study. In 2016, an estimated 48.0% (95% CI, 48.0%-48.0%) of health care spending was paid by private insurance, 42.6% (95% CI, 42.5%-42.6%) by public insurance, and 9.4% (95% CI, 9.4%-9.4%) by out-of-pocket payments. In 2016, among the 154 conditions, low back and neck pain had the highest amount of health care spending with an estimated $134.5 billion (95% CI, $122.4-$146.9 billion) in spending, of which 57.2% (95% CI, 52.2%-61.2%) was paid by private insurance, 33.7% (95% CI, 30.0%-38.4%) by public insurance, and 9.2% (95% CI, 8.3%-10.4%) by out-of-pocket payments. Other musculoskeletal disorders accounted for the second highest amount of health care spending (estimated at $129.8 billion [95% CI, $116.3-$149.7 billion]) and most had private insurance (56.4% [95% CI, 52.6%-59.3%]). Diabetes accounted for the third highest amount of the health care spending (estimated at $111.2 billion [95% CI, $105.7-$115.9 billion]) and most had public insurance (49.8% [95% CI, 44.4%-56.0%]). Other conditions estimated to have substantial health care spending in 2016 were ischemic heart disease ($89.3 billion [95% CI, $81.1-$95.5 billion]), falls ($87.4 billion [95% CI, $75.0-$100.1 billion]), urinary diseases ($86.0 billion [95% CI, $76.3-$95.9 billion]), skin and subcutaneous diseases ($85.0 billion [95% CI, $80.5-$90.2 billion]), osteoarthritis ($80.0 billion [95% CI, $72.2-$86.1 billion]), dementias ($79.2 billion [95% CI, $67.6-$90.8 billion]), and hypertension ($79.0 billion [95% CI, $72.6-$86.8 billion]). The conditions with the highest spending varied by type of payer, age, sex, type of care, and year. After adjusting for changes in inflation, population size, and age groups, public insurance spending was estimated to have increased at an annualized rate of 2.9% (95% CI, 2.9%-2.9%); private insurance, 2.6% (95% CI, 2.6%-2.6%); and out-of-pocket payments, 1.1% (95% CI, 1.0%-1.1%). Conclusions and Relevance:Estimates of US spending on health care showed substantial increases from 1996 through 2016, with the highest increases in population-adjusted spending by public insurance. Although spending on low back and neck pain, other musculoskeletal disorders, and diabetes accounted for the highest amounts of spending, the payers and the rates of change in annual spending growth rates varied considerably.

Project description:ImportanceSince 2014, all hospitals in Maryland have operated under an all-payer global budget system. Hospital global budgets have gained renewed attention as a strategy for constraining cost growth, improving patient outcomes, and preserving health care access in rural and underserved communities. Lessons from the implementation of the Maryland All-Payer Model (MDAPM) may have implications for policy makers, payers, and hospitals in other settings seeking to adopt global budgets or other value-based payment models.ObjectiveTo examine perspectives on the implementation of the MDAPM among health care leaders who participated in its design and execution.Design setting and participantsThis qualitative study with semistructured telephone interviews was conducted from November 1, 2019, to February 11, 2020. The purposive sample of Maryland health care leaders represents diverse stakeholder groups, including hospitals, state government and regulatory agencies, the federal government, and payers.Main outcomes and measuresKey high-level themes were extracted from interviews using qualitative content analysis, with barriers and facilitators to implementation specified within each theme.ResultsA total of 20 interviews were conducted with hospital leaders (n = 6), state regulators (n = 4), federal regulators (n = 4), payer representatives (n = 3), and state leaders (n = 3). Key themes were labeled as (1) expectations (setting bold yet achievable goals), (2) autonomy (allowing hospitals to follow individual strategies within MDAPM parameters), (3) communication (encouraging early and ongoing communication between stakeholders), (4) actionable data (sharing useful hospital and patient-level data between stakeholders), (5) global budget calibration (anticipating technical challenges when negotiating budgets for individual hospitals), and (6) shared commitment to change (harnessing collective motivation for system change). Together, these themes suggest that implementing the payment model followed an evolving and collaborative process that requires stakeholder communication, data to guide decisions, and commitment to operating within the new payment system.Conclusions and relevanceThe implementation of hospital global budgets in the state of Maryland offers generalizable lessons that can inform the evolution and expansion of this approach to value-based payment in other states and settings.

Project description:ImportanceSuicide is a public health problem, with multiple causes that are poorly understood. The increased focus on combining health care data with machine-learning approaches in psychiatry may help advance the understanding of suicide risk.ObjectiveTo examine sex-specific risk profiles for death from suicide using machine-learning methods and data from the population of Denmark.Design, setting, and participantsA case-cohort study nested within 8 national Danish health and social registries was conducted from January 1, 1995, through December 31, 2015. The source population was all persons born or residing in Denmark as of January 1, 1995. Data were analyzed from November 5, 2018, through May 13, 2019.ExposuresExposures included 1339 variables spanning domains of suicide risk factors.Main outcomes and measuresDeath from suicide from the Danish cause of death registry.ResultsA total of 14 103 individuals died by suicide between 1995 and 2015 (10 152 men [72.0%]; mean [SD] age, 43.5 [18.8] years and 3951 women [28.0%]; age, 47.6 [18.8] years). The comparison subcohort was a 5% random sample (n = 265 183) of living individuals in Denmark on January 1, 1995 (130 591 men [49.2%]; age, 37.4 [21.8] years and 134 592 women [50.8%]; age, 39.9 [23.4] years). With use of classification trees and random forests, sex-specific differences were noted in risk for suicide, with physical health more important to men's suicide risk than women's suicide risk. Psychiatric disorders and possibly associated medications were important to suicide risk, with specific results that may increase clarity in the literature. Generally, diagnoses and medications measured 48 months before suicide were more important indicators of suicide risk than when measured 6 months earlier. Individuals in the top 5% of predicted suicide risk appeared to account for 32.0% of all suicide cases in men and 53.4% of all cases in women.Conclusions and relevanceDespite decades of research on suicide risk factors, understanding of suicide remains poor. In this study, the first to date to develop risk profiles for suicide based on data from a full population, apparent consistency with what is known about suicide risk was noted, as well as potentially important, understudied risk factors with evidence of unique suicide risk profiles among specific subpopulations.

Project description:BackgroundThere are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care.MethodsThis was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply.ResultsAmong 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]).ConclusionsDespite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Project description:ImportanceMeasuring health care utilization and costs before death has the potential to initiate health care improvement.ObjectiveTo examine population-level trends in health care utilization and expenditures in the 2 years before death in Canada's single-payer health system.Design, setting, and participantsThis population-based cohort included 966 436 deaths among adult residents of Ontario, Canada, from January 2005 to December 2015, linked to health administrative and census data. Data for deaths from 2005 to 2013 were analyzed from November 1, 2016, through January 31, 2017. Analyses were updated from May 1, 2019, to June 15, 2019, to include deaths from 2014 and 2015.ExposuresSociodemographic exposures included age, sex, and neighborhood income quintiles, which were obtained by linking decedents' postal codes to census data. Aggregated Diagnosis Groups were used as a general health service morbidity-resource measure.Main outcomes and measuresHealth care services accessed for the last 2 years of life, including acute hospitalization episodes of care, intensive care unit visits, and emergency department visits. Total health care costs were calculated using a person-centered costing approach. The association of area-level income with high resource use 1 year before death was analyzed with Poisson regression analysis, controlling for age, sex, and Aggregated Diagnosis Groups.ResultsAmong 966 436 decedents (483 038 [50.0%] men; mean [SD] age, 76.4 [14.96] years; 231 634 [24.0%] living in the lowest neighborhood income quintile), health care expenditures increased in the last 2 years of life during the study period (CAD$5.12 billion [US $3.83 billion] in 2005 vs CAD$7.84 billion [US $5.86 billion] in 2015). In the year before death, 758 770 decedents (78.5%) had at least 1 hospitalization episode of care, 266 987 (27.6%) had at least 1 intensive care unit admission, and 856 026 (88.6%) had at least 1 emergency department visit. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Utilization in the last 2 years, 1 year, 180 days, and 30 days of life varied by resource utilization gradients. For example, the proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year of life (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]); however, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile (rate ratio, 1.02; 95% CI, 0.99-1.05) after adjusting for relevant covariates.Conclusions and relevanceIn this study, health care use and spending in the last 2 years of life in Ontario were high. These findings highlight a trend in hospital-centered care before death in a single-payer health system.

Project description:Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme (http://www.act-programme.eu). The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario.The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL).Responsible teams for regional data management in the five ACT regions.We characterised and compared risk assessment strategies among ACT regions by analysing operational health risk predictive modelling tools for population-based stratification, as well as available health indicators at regional level. The analysis of the risk assessment tool deployed in Catalonia in 2015 (GMAs, Adjusted Morbidity Groups) was used as a basis to propose how population-based analytics could contribute to clinical risk prediction.There was consensus on the need for a population health approach to generate health risk predictive modelling. However, this strategy was fully in place only in two ACT regions: Basque Country and Catalonia. We found marked differences among regions in health risk predictive modelling tools and health indicators, and identified key factors constraining their comparability. The research proposes means to overcome current limitations and the use of population-based health risk prediction for enhanced clinical risk assessment.The results indicate the need for further efforts to improve both comparability and flexibility of current population-based health risk predictive modelling approaches. Applicability and impact of the proposals for enhanced clinical risk assessment require prospective evaluation.

Dataset Information

What is Single-Payer Health Care? A Review of Definitions and Proposals in the U.S.

Background

Objective

Design

Main measures

Key results

Conclusions

Publications

What is Single-Payer Health Care? A Review of Definitions and Proposals in the U.S.

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