The U.S. Health Care Presentation: Part 1 AssignmentMust be 15 to 20 slides in length (not including title and references slides) and formatted to APA Must include a separate title slide with the following: Title of presentation Student’s name Course name and number Instructor’s name Date submittedIntroduction:Create an overview slide that describes the required components to be covered within the presentation. Add bullet points for each of the topics being covered. Briefly describe each bullet point in the speaker’s notes.Content:The remaining slides will address the content of the presentation and the references. The content will address the following required components: Choose one revolutionary factor from each of the centuries (17th, 18th, 19th, 20th, and 21st) found in your textbook and time line. Describe each revolutionary factor. Discuss how the revolutionary factors changed the health care system.o Refer to the time line simulation Global Perspectives: Shifts in Science and Medicine That Changed Healthcare (Links to an external site.)Links to an external site. reviewed in Week 1. Chapter 2 in your textbook discusses the evolution of our health care system and is a good resource for this part of the presentation as well. Identify at least one major development from each of the following perspectives: financial, legal, ethical, regulatory, and social (e.g., consumer demand). Discuss how each development transformed the system into what it is For more perspective, you may want to review the time line simulation Global Perspectives: Shifts in Science and Medicine That Changed Healthcare (Links to an external site.)Links to an external site.. Choose three different stakeholders that have affected the health care system (e.g., health care professionals [physicians, nurses, etc.], clients [patients], health insurance plans [Blue Cross Blue Shield, managed care organizations (MCOs), etc.], federal or state governments, health care professional organizations [American Medical Association (AMA), American Nurses Association (ANA), etc.] and health care accreditation agencies [Centers for Medicare and Medicaid Services (CMS), The Joint Commission, National Committee for Quality Assurance (NCQA), etc.]).o Evaluate each stakeholder’s effect on the health care system by discussing their purpose and impact.o Include examples of both positive and negative impacts made by your chosen stakeholders (e.g., a negative contribution is when a patient uses the emergency room for non-urgent care).Part 2: The Cost of the U.S. Health Care System Describe three different reimbursement methods (e.g., capitation, fee-for-service [FFS], pay-for-performance [P4P], value-based, episode of care, prospective reimbursement, diagnosis related group [DRG], patient-centered medical home [PCMH]).o Explain why you think one of the reimbursement methods you discussed is more effective at reducing health care costs overall while still ensuring the delivery of quality care. Describe the use of two technological advancements (e.g., electronic medical record [EMRs], electronic health records [EHRs], medical research, improved equipment like magnetic resonance imaging [MRI], mammography, personalized medicine, mobile services like e-prescribing, disease registries, ).o Explain why you think these advancements have reduced costs overall while still ensuring the delivery of quality care.Part 3: The United States Versus Other Health Care Systems: An International Perspective Contrast the S. health care system with another country (e.g., Canada’s universal health care or South Africa compared with the U.S. health care system, etc.). You can use the same country discussed in the Week 4 Health Care Systems Around the World discussion.o Discuss how the other country’s health care system is funded.o Discuss disparities in health care from your chosen country.o Include at least one positive aspect from the other country’s health care system that you would like to see added to the S. health care system, explaining why you would like this addition.Part 4: Reforms and Improvements Describe two potential reforms and improvements currently being debated at either the local, state, or federal You may want to review the Laws and Regulations Affecting Health Care discussion prompt to help you with this component. Examples could include any of the following:o Federal modifications (e.g., antitrust reforms, CHIP, HSA or HRA, Medicare reform, Medicaid expansion, PPACA repeal, pharmaceutical regulations, development of a universal system, veterans’ health care, crossing borders for health care, clinical trial research, )o State modifications (e.g., Medicaid reform, income tax credits, adoption of state level universal health care, etc.)o Increased consumer controls (e.g., patient-centered care, provider choice, complementary and alternative care choices, activism for changes at the state and federal level, etc.)o Reimbursement changes (Medicare, Medicaid, managed care plans, traditional insurance plans, etc.)Part 5: Conclusion: The Future of the U.S. Health Care System Examine what you believe the U.S. health care system will resemble in the next 10 years by recommending two changes and addressing access to care, quality of care, and cost of care, including an example of each in your vision of the future health care system.ADDITIONAL BREAKDOWN OF REQUIREMENTS BELOW: FOR PART 1 – You needed to include the revolutionary factors, the 3 different stakeholders and their roles, both positive and negative, and at least one major development from the financial, legal, ethical, regulatory and social. Plus all of the bullet items under each of the require components. Items often missed in the presentation:Financial: 1. How has reimbursement to physicians changed? Has it affected our health care system, if so how? 2. How have costs for insurance changed over the years? How has it effected employers and patients? Legal:1. Have there been any legal challenges of our health care system over the years? 2. What are the laws that have affected our system? Did they affect it positively or negatively? Ethical:1. Are there any ethical considerations regarding health care? Think about health care professionals and their ethics in delivering quality care.2. What are the ethical considerations for insurance companies, pharmaceutical companies….etc? Think about the recent news about the Epipen… the pharmaceutical companies raised the prices sky high so people could not afford it… Regulatory:1. Have there been any regulations from the government or health insurance plans that have affected our health care system? Good or bad? Social (Consumer Demand):1. What are the demands made by the consumer for our health care system?2. How has the increased need for access (more patients being insured) affected our health care system?3. Has the consumer had a good or bad effect on our health care system? If so, good or bad? The Cost of the U.S. Healthcare System1. Describe three different reimbursement methods. Make sure to explain why you think one of the reimbursement methods you discussed is more effective than the others (see directions for specifics).2. Describe the use of two technological advancements. Make sure to include information on why you think these advancements in technology have reduced costs while delivering quality care. PART 3: The United States Versus Other Health Care Systems—an International Perspective1. Contrast the U.S. health care system with at least one other (e.g., Canada’s universal health care vs. U.S. healthcare or South Africa vs. U.S. health care, etc.). Make sure to review the directions for specifics information you need to include. PART 4: Reforms and Improvements1. Describe any potential healthcare reforms and/or improvements that are currently being discussed at either the local, state, or the federal level (review the directions for specifics).CONCLUSION: Future of the U.S. healthcare system1. Explain what you believe the U.S. healthcare system will look like in the next 10 years. Give at least two recommendations for change.2. Address access to care, quality of care, and cost of care including an example of each in your vision of our future healthcare system.APA FORMATTING & REFERENCE SLIDE: 1. You must have a title slide that includes your personal introduction. Make sure to introduce yourself.2. You must have an overview slide, which gives a brief overview of what you will be covering in the presentation.3. You must have citations for each reference used. The citations belong in the speaker notes with the detail that explains each of the bullet points on the slide.4. You must have speaker notes for each slide. 5. You must have a reference slide that lists your references. They must be in APA format.
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Medicine Through Time Timeline
Pre-History – understanding is based on spirits and gods. No
real medical care. People die very young, normally by the age of
30-35 for men, but only 15-25 for women due to the dangers of
childbirth. Most people suffered osteoarthritis (painful swelling
of the joints).
Egyptian Empire – development of papyrus, trade and a greater
understanding of the body (based on irrigation channels from
the River Nile). They believed the body had 42 blood channels
and that illness was caused by undigested food blocking these
Greek Empire – Medicine still based on religion – Temple of
Asclepius. Here, patients would get better, but mainly through
the standard of rest, relaxation and exercise (like a Greek
Hippocrates – founder of the Four Humours theory. This theory
stated that there were four main elements in the body – blood,
yellow bile, black bile and phlegm. Illness was caused by having
too much of one of these humours inside of you. He also wrote
the Hippocratic Collection, more than 60 books detailing
symptoms and treatments of many diseases.
400 BC –
Roman Empire – The Romans were renowned for excellent public
health facilities. The Romans introduced aqueducts, public
baths, sewers and drains, etc. In the citcy of Rome, water
commissioners were appointed to ensure good supplies of clean
Galen – continues the four humours theory but extends it to
have the humours in opposition to each other. This meant that
an illness could be treated in one of two ways, either removing
the “excess” humour or by adding more to its opposite. Galen
also proves the brain is important in the body (operation on the
pig). Galen’s books would become the foundation of medical
treatment in Europe for the next 1500 years.
Britain and Europe return almost back to pre-historic times
under Saxons & Vikings
Battle of Hastings – Normans invade Britain
When Europeans went on crusades to the Holy Land in the 12th
and 13th centuries, their doctors gained first-hand knowledge
of Arab medicine, which was advanced by Western standards.
Black Death – across Europe more than 25 million people die.
Two main types of plague
1. Bubonic – 50-75% chance of death. Carried by fleas on
rats. Death usually within 8 days
2. Pneumonic – airborne disease. 90-95% chance of death
within only 2-3 days
People had no idea how to stop the plague. People thought it was
caused by various factors, i.e. the Jews, the Planets, the Gods,
etc etc etc
The Printing Press was invented by Johannes Gutenberg. This
allowed for the massive reproduction of works without using the
Church as a medium.
Martin Luther posted his “Ninety-Five Theses” on the door of a
Catholic Church in Germany. This began the Protestant
Andreus Vesalius – proved Galen wrong regarding the jawbone
and that blood flows through the septum in the heart. He
published “The Fabric of the Body” in 1543. His work
encouraged other to question Galen’s theories.
Ambroise Paré – developed ligatures to stop bleeding during
and after surgery. This reduced the risk of infection. He also
developed an ointment to use instead of cauterising wounds.
William Harvey – proved that blood flows around the body, is
carried away from the heart by the arteries and is returned
through the veins. He proved that the heart acts as a pump recirculating the blood and that blood does not “burn up”.
The Great Plague – little improvement since 1348 – still have no
idea what is causing it and still no understanding of how to
control or prevent it. In London, almost 69,000 people died that
Antony van Leeuwenhoek creates a superior microscope that
magnifies up to 200 times. This is a huge improvement on
Robert Hooke’s original microscope.
Inoculation first used in Europe, brought over from Turkey by
Edward Jenner – discovered vaccinations using cowpox to treat
smallpox. Jenner published his findings in 1798. The impact was
slow and sporadic. In 1805 Napoleon had all his soldiers
vaccinated. However, vaccination was not made compulsory in
Britain until 1852.
Humphrey Davy discovers the pain-killing attributes of Nitrous
Oxide (Laughing Gas). It would become the main anaesthetic
used in Dentistry. Horace Wells would try and get the gas
international recognition. He committed suicide the day before
it got the recognition it deserved.
Industrial Revolution. This had a dramatic effect on public
health. As more and more families moved into town and cities,
the standards of public health declined. Families often shared
housing, and living and working conditions were poor. People
worked 15 hour days and had very little money.
Cholera Epidemic. People infected with cholera suffered
muscle cramps, diarrhoea , dehydration and a fever. The patient
would most likely be killed by dehydration. Cholera returned
regularly throughout the century, with major outbreaks in 1848
Edwin Chadwick reports on the state of health of the people in
cities, towns and villages to the Poor Law Commission (forerunner to the Public Health Reforms). He highlights the
differences in life-expectancy caused by living and working
conditions. He proposes that simple changes could extend the
lives of the working class by an average of 13 years.
First successful use of Ether as an anaesthetic in surgery. The
anaesthetic had some very severe drawbacks. In particular, it
irritated the lungs and was highly inflammable.
James Simpson discovers Chloroform during an after dinner
sampling session with friends. He struggles to get the medical
world to accept the drug above Ether. Doctors were wary of
how much to give patients. Only 11 weeks after its first use by
Simpson, a patient died under chloroform in Newcastle. The
patient was only having an in-growing toenail removed (non-life
threatening). It took the backing of Queen Victoria for
chloroform and Simpson to gain worldwide publicity.
Ignaz Semmelweiss orders his students to wash their hands
before surgery (but only after they had been in the morgue).
Elizabeth Blackwell becomes the first woman doctor in USA
First Public Health Act in Britain – It allowed local authorities
to make improvements if they wanted to & if ratepayers gave
them their support. It enabled local authorities to borrow
money to pay for the improvements. It was largely ineffective
as it was not made compulsory for Councils to enforce it. This
was an element of the “Laissez-Faire” style of government.
Crimean War – Florence Nightingale and Mary Seacole
contribute majorly to the improvements in Hospitals.
John Snow proves the link between the cholera epidemic and
the water pump in Broad Street, London. Unfortunately, he was
unable to convince the government to make any substantial
Queen Victoria publicly advocates use of Chloroform after
birth of her eighth child.
Doctors’ Qualifications had to be regulated through the
General Medical Council.
Germ Theory developed by Louis Pasteur whilst he was working
on a method to keep beer and wine fresh – changed the whole
understanding of how illnesses are caused.
Elizabeth Garrett-Anderson – first female doctor in the UK
Joseph Lister begins using Carbolic Spray during surgery to
fight infection. It reduces the casualty rate of his operations
from 45.7% of deaths to just 15.0 % dying.
Second Public Health Act – now made compulsory. Major
requirement is that sewers must be moved away from housing
and that houses must be a certain distance apart.
Public Health improvements – in the UK, the government
introduced new laws against the pollution of rivers, the sale of
poor quality food and new building regulations were enforced.
Robert Koch discovers the bacteria that causes anthrax. He
establishes a new method of staining bacteria. Using Koch’s
methods, the causes of many diseases were identified quickly:
1880 – Typhus
1882 – Tuberculosis
1883 – Cholera
1884 – Tetanus
1886 – Pneumonia
1887 – Meningitis
1894 – Plague
1898 – Dysentery
Isolation Hospitals were set up to treat patients with highly
William Röntgen discovers X-Rays. Though it is an important
discovery, it is only WW1 and the treatment of soldiers that
propels it into the medical spotlight.
Marie Curie discovers radioactive elements radium and polonium
Scientists discover that there are different blood groups- this
leads to the first 100% successful blood transfusions.
Paul Ehrlich discovers first “magic bullet” – Salvarsan 606 to
treat Syphilis. The problem was it was based on arsenic and so
could kill the patient too easily.
National Health Insurance introduced in Britain
World War One – development of skin grafts to treat victims
Alexander Fleming – discovers Penicillin. The mould had grown
on a petri dish that was accidentally left out. Fleming writes
articles about the properties of Penicillin, but was unable to
properly develop the mould into a drug.
Gerhardt Domagk discovers Prontosil (the second magic
bullet). Slight problem is that it turns the patient red.
Florey, Chain & Heatley work on producing penicillin as a drug.
Their success will make the drug the second most finded
project by the USA in WW2. They fund it to the tune of $800
million and every soldier landing on D-Day in 1944 has Penicillin
as part of his medical kit.
Emergency hospital scheme introduced – Funded and run by
William Beveridge publishes the Beveridge Report. The report
was the blueprint for the NHS
National Health Service Act – provides for a free and
comprehensive health service. Aneurin Bevan convinces 90% of
the private doctors to enrol.
First day of the NHS. Hospitals were nationalised, health
centres were set up and doctors were more evenly distributed
around the country. However, the popularity and costs of the
NHS would rapidly spiral out of control. The £2 million put
aside to pay for free spectacles over the first nine months of
the NHS went in six weeks. The government had estimated that
the NHS would cost £140 million a year by 1950. In fact, by
1950 the NHS was costing £358 million.
William Bigelow (Canadian) performed the first open-heart
surgery to repair a ‘hole’ in a baby’s heart, using hypothermia.
First kidney transplant (America)
Charges introduced in NHS – 1s for a prescription
Description of the structure of DNA
Contraceptive pill introduced
Christiaan Barnard (South Africa) performed the first heart
transplant – the patient lived for 18 days
First test tube baby
Increasing use of keyhole surgery, using endoscopes and
ultrasound scanning, allowed minimally invasive surgery.
National Organ Donor register created
MCRXXX10.1177/1077558715615774Medical Care Research and ReviewConrad et al.
Reform: A Conceptual
Framework and Case
Medical Care Research and Review
2016, Vol. 73(4) 437–457
© The Author(s) 2015
Reprints and permissions:
Douglas A. Conrad1, Matthew Vaughn1,
David Grembowski1, and Miriam Marcus-Smith1
This article develops a conceptual framework for implementation of value-based
payment (VBP) reform and then draws on that framework to systematically
examine six distinct multi-stakeholder coalition VBP initiatives in three different
regions of the United States. The VBP initiatives deploy the following payment
models: reference pricing, “shadow” primary care capitation, bundled payment,
pay for performance, shared savings within accountable care organizations, and
global payment. The conceptual framework synthesizes prior models of VBP
implementation. It describes how context, project objectives, payment and care
delivery strategies, and the barriers and facilitators to translating strategy into
implementation affect VBP implementation and value for patients. We next apply
the framework to six case examples of implementation, and conclude by discussing
the implications of the case examples and the conceptual framework for future
practice and research.
value-based payment, implementation, conceptual framework
This article, submitted to Medical Care Research and Review on April 9, 2015, was revised and accepted
for publication on October 12, 2015.
of Washington, Seattle, WA, USA
Douglas A. Conrad, Department of Health Services, University of Washington, Box 357660, Seattle,
WA 98105-5660, USA.
Email: [email protected]
Medical Care Research and Review 73(4)
Health care purchasers, plans, and providers in the United States are positioning themselves to move from the dominant payment model of fee-for-service (FFS) to payment
based on value. This evolution is being driven by a combination of forces. Purchasers
(e.g., Medicare and Medicaid, employers, and union trusts) are seeking increased value
in health plan benefits and in health care for their employees and members. Insurance
plans are searching for payment models and aligned benefit designs that will lead to
improved health and health care quality and patient experience at least cost. Provider
organizations and individual providers are trying to build efficient organizational and
care delivery infrastructure and to escape the “hamster wheel” of volume-driven scheduling and patient care to generate revenue; they are adopting payment models that promote clinical practice to improve health. Value-based payment (VBP) reform seeks to
change the behavior of individual providers and provider organizations by aligning
payment with value. VBP models assume a variety of forms, but are operationally
defined as financial incentives that aim to improve clinical quality and outcomes for
patients, while simultaneously containing (or better yet) reducing health care costs.
This article’s objectives are the following:
To present a conceptual framework for evaluating the implementation of multistakeholder VBP initiatives, drawing primarily on previous models of VBP
implementation (Damschroder et al., 2009; McHugh & Joshi, 2010) and secondarily on models attempting to explain the impact of VBP on cost, quality,
and outcomes (Conrad & Christianson, 2004; Damberg et al., 2014; Dudley
et al., 2004; Hussey, Mulcahy, Schnyer, & Schneider, 2012).
To apply the conceptual framework to VBP implementation in different
To articulate a set of insights for practice and research, based on particular
projects and VBP methods, and where possible to present a set of more general, cross-cutting lessons for implementing VBP reform.
The six VBP initiatives examined in this article were chosen from 11 pilots funded
by the Robert Wood Johnson Foundation (RWJF) and evaluated by University of
Washington researchers. We selected them purposefully to capture a broad array of
VBP approaches: shared savings-based accountable care organizations (ACOs), bundled payment, pay-for-performance (P4P), reference pricing, “shadow primary care
capitation,” and global payment. RWJF chose to fund multi-stakeholder coalitions that
submitted “bold” and “innovative” payment reform proposals and that made a strong,
credible case for development, spread, and sustainability of VBP innovation. As evaluators we studied the implementation of each initiative in detail and documented the
context, objectives, payment and delivery reform strategy, logic model, barriers and
facilitators, progress and results, and lessons learned for each project. We intentionally
did not label different efforts as “successes” or “failures,” but sought to develop
insights for practice and research from each project and (where possible) general lessons based on these multiple case studies.
Conrad et al.
This article’s original contribution is twofold: (1) offer a conceptual framework
for the implementation of VBP through a multi-stakeholder approach, synthesizing prior implementation research (cf. Damberg et al., 2014; Damschroder et al.,
2009; McHugh & Joshi, 2010) and insights from empirical work on the impact of
VBP; and (2) apply that framework to six recent initiatives in implementing VBP
through a multi-stakeholder approach, rather than through single payer–provider
innovation. The analysis stresses implementation—not impact—in light of the
early development stage of our six case examples, the paucity of research on
implementing VBP, and realizing that implementation is a precondition for such
reform to affect the Triple Aim.
Implementation. The results of payment reform implementation are not affected only
by the type of payment, but are heavily influenced by characteristics of the organization and environment. A separate field of study, implementation science, has arisen to
better understand the factors which moderate the path from program implementation
to observed results. Theoretical models seek to explain the effectiveness of any change
effort—based on individual- or organizational-level characteristics alone (Ajzen,
1991; Prochaska & Velicer, 1997; Rosenstock, Strecher, & Becker, 1988; Weiner,
2009), or a combination of internal and external environmental factors (McLaren &
Hawe, 2005; Stokols, 1996).
To understand the full range of influences on effectiveness of change initiatives,
recent meta-analyses and systematic reviews of constructs from empirical studies and
conceptual models led to the development of the Consolidated Framework for
Implementation Research (Damschroder et al., 2009; Durlak & DuPre, 2008). This
framework identified several moderating factors that might influence observed results:
structural, organizational, provider, and innovation attributes. Structural factors
embody the larger social and political context of change initiatives, organizational factors relate to internal leadership and culture, and provider and innovation factors relate
to interpersonal characteristics of individuals who carry out change. Application of
these factors to explain the effects of health innovations seems to have been uneven. A
recent systematic review of studies indicated that organization-, provider-, and individual-level measures are most often assessed, whereas structural and patient characteristics, which may have an equal if not greater influence on results, are less frequently
examined (Chaudoir, Dugan, & Barr, 2013).
Specific to payment reform efforts in health care delivery systems, implementation
factors are not consistently assessed or well understood for different models. For
example, in reference pricing, the importance of health care consumer characteristics
and regulatory agencies has been identified, but the exact influence of these factors on
the design and results of reforms remains unclear (Robinson & MacPherson, 2012). A
systematic review of P4P studies reports that the incentive performance measures,
type of provider groups involved, level of incentive (provider vs. team), and type of
Medical Care Research and Review 73(4)
incentive all influenced reform effects. However, little evidence addressed the influence of patient characteristics, and structural factors were not examined in depth (Van
Herck et al., 2010).
A nationwide survey of patient-centered medical home demonstration projects
illustrated many of the local contextual factors that shaped implementation; however,
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