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Viewpoints, February 20 Issue Of JAMA – US Health Care, Access & Reimbursement Policy And Atherosclerotic Renal Artery Stenosis Treatment

Reengineering U.S.

Ari Hoffman, M.D., of , San Francisco, and Ezekiel J. Emanuel, M.D., Ph.D., of , Philadelphia, write that “ requires fixing a chronically dysfunctional system. While it is tempting to try to identify a single solution to this complex problem, the cure will require a multimodality approach with a focus on reengineering the entire care delivery process.”

In this Viewpoint, the authors examine the issue of reengineering the U.S. health care system. “With a focus on reengineering, the nation may succeed not only in implementing systematic health care reform, but reform that actually improves the health of Americans while simultaneously controlling unsustainable costs.”

(. 2013;309[7]:661-662 – An author podcast on this article will be available post-embargo on the website.)

Treatment of Atherosclerotic

Peter W. de Leeuw, M.D., Ph.D., of the University Hospital Maastricht and Cardiovascular Research Institute Maastricht, the Netherlands, and colleagues discuss the diagnosis and treatment of atheroscle­rotic renal artery stenosis.

“From a scientific perspective, it is worthwhile to explore whether angioplasty added to optimal anti-atherosclerotic treatment will produce a better outcome in terms of renal function than medical treatment alone. This could be investigated in a clinical trial conducted among patients with hypertension and low-grade renal artery stenosis. On a broader scale, failure of trials to show an expected outcome should serve as motivation to reconsider the pathophysiological principles behind the treatment rather than abandon the treatment.”

(JAMA. 2013;309[7]:663-664)

Policy Responses to Demand for Health Care Access

Katherine Diaz Vickery, M.D., of the University of Michigan, Ann Arbor, and colleagues write that the Emergency Medical Treatment and Active Labor Act (EMTALA), signed into law in 1986, was “intended by Congress to impart a social contract between the health care-seeking public and a U.S. health care system that the public progressively distrusted.”

“Examining where and how EMTALA fell short highlights how the Affordable Care Act can start to construct a system founded on shared societal obligations to health. The path forward in U.S. health care reform lies in recognizing the shared ethical standard that supersedes political differences.”

(JAMA. 2013;309[7]:665-666)

Realigning Reimbursement Policy and Financial Incentives to Support Patient-Centered Out-of-Hospital Care

“… little consideration has been given to how fee-for-service reimbursement in out-of-hospital care limits the ability of emergency medical services (EMS) to provide more patient-centered care and reduce downstream health care costs,” writes Kevin Munjal, M.D., M.P.H., of the Mount Sinai Medical Center, New York, and Brendan Carr, M.D., M.S., of the University of Pennsylvania, Philadelphia.

“Current Medicare reimbursement policies for out-of-hospital care link payment to transport to an emergency department. This provides a disincentive for EMS agencies to work to reduce avoidable visits to emergency departments, limits the role of prehospital care in the U.S. health system, is not responsive to patients’ needs, and generates downstream health care costs. Financial and delivery model reforms that address EMS payment policy may allow out-of-hospital care systems to deliver higher-quality, patient-centered, coordinated health care that could improve the public health and lower costs.”

(JAMA. 2013;309[7]:667-668)


Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.