Stuart H. Altman

Adverse Events and Preventable Adverse Events in Children

Context. Patient safety has been recognized as an important problem in health care. However, knowledge about adverse events and preventable adverse events in children is relatively limited. Objective. To describe the incidence and types of adverse events and preventable adverse events in children. Design. Analysis of pediatric hospitalizations in the Colorado and Utah Medical Practice Study, which involved a retrospective, 2-level (nurse and physician) medical record review of a population-based, representative sample of all pediatric hospital discharges. Main Measures. Adverse events were defined as an injury caused by medical management rather than disease processes that resulted in either prolonged hospitalization or disability at discharge. A preventable adverse event was defined as an avoidable adverse event based on currently available knowledge and accepted practices. Patients. 3719 discharged hospital patients, 0–20 years old, and 7528 nonelderly (21–65 years old) discharged adult patients in Colorado and Utah. Setting. All hospitals in Colorado and Utah. Results. Adverse events occurred in 1% of pediatric hospitalizations in Colorado and Utah; 0.6% were preventable. Preventable adverse events rates were 0.53% in neonates and infants (0–0.99 years), 0.22% in children 1–12 years of age, and 0.95% in adolescents 13–20 years of age, compared with a rate of 1.50% in nonelderly adults. Of preventable adverse event types, birth related (32.2%) and diagnostic related (30.4%) events were the most common and were significantly more common than surgically related preventable adverse events (3.5%). Conclusions. These data suggest that ∼70 000 children hospitalized in the United States experience an adverse event each year; 60% of these events may be preventable. The epidemiology of adverse events and preventable adverse events in children is different than in adults. To reduce the adverse events that occur in hospitalized children, research should focus on adolescent hospitalized patients, birth-related medical care, and diagnostics in pediatric medicine.

A Systemic Approach to Containing Health Care Spending

Two Sounding Board articles, by Emanuel et al. and Antos et al., discuss different approaches to controlling rising health care costs in the United States. The editors hope that the range of options presented will stimulate discussion and debate on the best ways to bend the health care cost curve.

Payment Reform Options: Episode Payment Is A Good Place To Start

New strategies to control U.S. health spending growth are urgently needed. Although provider payment cuts are likely, cutting fee-for-service (FFS) payments will hurt quality and access. A more sensible approach would be to restructure the delivery system into organized networks of providers delivering reliable, evidence-based care. But restructuring will not occur without payment policy reform. Four policy options are commonly cited: recalibrating FFS, instituting pay-for-performance, creating episode-based payments, and adopting global payments. We argue that episode payments are the most immediately viable approach, and we recommend that payment reforms precede any payment reductions so that new delivery models can gain traction.

Earnings, Unemployment, and the Supply of Enlisted Volunteers.

If the draft is to be eliminated and an all-volunteer system substituted in its place, it is essential that the military be able to recruit additional personnel through higher pay. In this study an attempt is made to measure the likely impact on new enlistments of raising military pay by estimating the extent to which regional enlistments have varied in relation to relative military to civilian earnings. A cross-section supply model was estimated using actual with-draft enlistment experience and estimates of the enlistment rates that would have prevailed without a draft. The supply elasticities derived in the paper tend to support the conclusion that volunteers could be attracted to active duty by raising military pay, but that the larger the proportion of the eligible population in military service, the more expensive it would become to recruit additional manpower.

Medicare's Opportunity to Encourage Innovation in Health Care Delivery

Congressional reform proposals include a new Center for Medicare and Medicaid Innovation intended to facilitate beneficial delivery-system changes. Robert Mechanic and Stuart Altman write that the long-term effect on the U.S. health care system could be priceless.

Should we worry about hospitals' high administrative costs?

In a health care world of negotiated budgets and cost-based reimbursement, it was important for those who paid the bills to focus on the individual cost items that were presented for reimbursement....

An examination of factors in the withdrawal of managed care plans from the Medicare+Choice program.

Participation of health maintenance organizations (HMOs) in the Medicare +Choice program, expected to rise rapidly after passage of the Balanced Budget Act of 1997, has gone in just the opposite direction. Because plans have left in such large numbers, Congress has taken remedial measures to remove restrictions and increase payments. To date these efforts have failed. This paper uses plan organizational characteristics, market position, and financial performance to quantify the reasons why some HMOs exited at the end of 1998. The findings suggest HMO participation in Medicare +Choice will continue to fall unless major changes are made to the overall Medicare program and the method of paying HMOs.

Implementing Change: Lessons for Medicaid Reformers

Major Medicaid reforms initiated in Arizona, California, and New York in the 1980s form the foundation of this study, which explores issues to consider when implementing change in state Medicaid programs. We prepared case studies of these reforms, describing the innovations and assessing the implementation process in each state. These case studies are used to illustrate broad issues and processes of Medicaid reform. Six lessons emerge from our analysis: Expect reform models to change over time; strive for predictability and continuity in the reform; encourage behavior changes through the use of incentives; use special administrative or political channels to simplify the reform; expect reform models to converge over time; and implementation difficulties can be predicted. These lessons should educate decision makers about how to implement possible future solutions to problems like those seen in Medicaid programs at the start of this decade.

The Value Proposition for Individuals and the Public

The Patient Protection and Affordable Care Act of 2010 represents the single most important piece of healthcare legislation since the passage of Medicare and Medicaid in 1965. When fully implemented, the law will extend insurance coverage to over 30 million Americans who had previously lacked insurance while also reforming the market for individual and small group insurance. Those who are unable to obtain health insurance through their employers will now have reliable options for obtaining insurance on their own. Although many object to some of its provisions, the Act achieves major accomplishments by extending health coverage to millions of Americans, enacting much needed reforms of private insurance market and putting in place numerous provisions that over time represent the best options of controlling the inexorable growth in the costs of providing health care to US citizens. Moreover, the status quo that many long for is likely an illusion, as accelerating rates of loss of private insurance coverage that had been present prior to enactment would likely have continued unabated.

The Affordable Care Act as Translational Research

The Affordable Care Act is the biggest U.S. health care policy experiment since Medicare and deserves our support.