Healthcare Contracts Limitations Essay

On October 12, 2017, through Executive Order 13813, you directed the Administration, to
the extent consistent with the law, to facilitate the development and operation of a health
care system that provides high-quality care at affordable prices for the American people by
promoting choice and competition. We are pleased to provide you with this report,
prepared by the Department of Health and Human Services (HHS) in collaboration with
the Departments of the Treasury and Labor, the Federal Trade Commission, and several
offices within the White House. This report describes the influence of state and federal
laws, regulations, guidance, and polices on choice and competition in health care markets
and identifies actions that states or the Federal Government could take to develop a better
functioning health care market.Healthcare Contracts Limitations Essay

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As health care spending continues to rise, Americans are not receiving the commensurate
benefit of living longer, healthier lives. Health care bills are too complex, choices are too
restrained, and insurance premiums and out-of-pocket costs are climbing faster than wages
and tax revenue. Health care markets could work more efficiently and Americans could
receive more effective, high-value care if we remove and revise certain federal and state
regulations and policies that inhibit choice and competition.
The Administration has already taken significant steps to improve health care markets by
addressing government rules and programs that limit choice and competition and produce
higher prices for the American people. Among the most significant actions:
 In October 2018, the Departments of HHS, the Treasury, and Labor proposed a
rule that would provide employers with significant new flexibility in how they
fund health coverage through Health Reimbursement Arrangements (HRAs). If
finalized, this flexibility would empower individuals to take greater control over
what health insurance benefits they receive. The Treasury estimates that more
than 10 million employees would benefit from this change within the next decade.Healthcare Contracts Limitations Essay
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Reforming America’s Healthcare System Through Choice and Competition
 In August 2018, the Departments of HHS, the Treasury, and Labor finalized a rule
to expand Americans’ ability to purchase short-term, limited-duration insurance—
coverage for which premiums are generally much more affordable than
Affordable Care Act (ACA) plans. Millions of Americans, including middle-class
families who cannot afford ACA plans, will benefit from the additional choice
and competition resulting from this reform.
 In June 2018, the Labor Department finalized a rule to expand the ability of
employers, including sole proprietors without common law employees, to join
together and offer health coverage through Association Health Plans. For many
employers, employees, and their families, these employee benefit plans will offer
greater flexibility and more affordable benefits.
 In May 2018, HHS released “American Patients First,” a historic blueprint for
actions to bring down the high price of drugs and reduce out-of-pocket costs.
HHS has taken a number of actions that were laid out in the blueprint to empower
consumers and promote competition, building on accomplishments such as the
Food and Drug Administration’s record pace of generic drug approvals.
 In December 2017, you signed the Tax Cuts and Jobs Act, which eliminated the
onerous and regressive individual mandate tax penalty. This freed Americans to
finance their health care needs in the way that works best for them.
 The Administration has enacted reforms to deliver better value through choice
and competition in the Medicare program, including payment changes that
establish site-neutral payment policies for a number of Medicare services, a
simplification of how physicians are paid for evaluation and management visits,
new consumer-transparency measures, and flexibility for insurers to offer more
options and benefits in Medicare Advantage.
 HHS and the Treasury have issued revised guidance under section 1332 of the
ACA that significantly expands the ability of states to reform their individual
insurance markets while ensuring that people with pre-existing conditions are
protected.Healthcare Contracts Limitations Essay
While the Administration has made much progress in reforming the American health care
system significant obstacles remain. This report identifies four areas where federal and
state rules inhibit adequate choice and competition and offers recommendations for
improving public policy in each of these four areas.
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Reforming America’s Healthcare System Through Choice and Competition
Health Care Workforce and Labor Markets: Reduced competition among clinicians
leads to higher prices for health care services, reduces choice, and negatively impacts
overall health care quality and the efficient allocation of resources. Government policies
have suppressed competition by reducing the available supply of providers and restricting
the range of services that they can offer. This report recommends policies that will broaden
providers’ scope of practice while improving workforce mobility, including telehealth, to
encourage innovation and to allow providers more easily to meet patients’ needs. The
report also recommends that the Federal Government streamline funding for graduate
medical education to allocate taxpayer dollars efficiently and to address physician supply
shortages.
Health Care Provider Markets: State policies that restrict entry into provider markets
can stifle innovative and more cost-effective ways to provide care while limiting choice
and competition. These policies have resulted in higher health care prices and fewer
incentives for providers to improve quality. This report makes several recommendations
to promote choice and competition in provider markets, including state action to repeal or
scale back Certificate of Need laws and encourage the development of value-based
payment models that offer flexibility and risk-based incentives for providers, especially
without unduly burdening small or rural practices.
Health Care Insurance Markets: Government mandates often reduce choice and
competition in insurance markets and increase overall premiums. In the individual and
small group markets, many consumers face limited coverage options that cover services
they do not want or need and that drive up premiums, while others have been completely
priced out of the market. Regulations that limit coverage choices should be changed so
that states have more flexibility to develop policies that account for diverse consumer
preferences. This report recommends scaling back government mandates, eliminating
barriers to competition, and allowing consumers maximum opportunity to purchase health
insurance that meets their needs.Healthcare Contracts Limitations Essay
Consumer-Driven Health Care: Our health care system’s excessive reliance on thirdparty payment insulates consumers from the true price of health care and offers them little
incentive to search for low-cost, high-quality care. When federal and state health policies
give consumers more control over their health care dollars, they can use that power to
demand greater value. For example, promoting and expanding Health Saving Accounts
(HSAs) and HRAs would expand personal control and introduce more consumer power
into the health care market. The report recommends expanding access to HSAs,
implementing reference pricing where appropriate, and developing price and quality
transparency initiatives to ensure that newly empowered health care consumers can make
well-informed decisions about their care.
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Reforming America’s Healthcare System Through Choice and Competition
We know the United States health care system too often fails to deliver the value it should.
This report identifies barriers on the federal and state levels to market competition that
stifle innovation, lead to higher prices, and do not incentivize improvements in quality. It
recommends policies that will foster a health care system that delivers high-quality care at
affordable prices through greater choice, competition, and consumer-directed health care
spending. While American consumers and many providers would significantly benefit
from the reforms laid out in this report, there are entrenched and powerful special interest
groups that reap large profits from the status quo. It will take bold leadership to confront
these incumbents and implement reforms, but under your direction, we are convinced we
can significantly improve the American health care system.
We look forward to working with you as we create a more effective and efficient health
care market that provides information for consumers as they make health care decisions
for their families, rewards quality

As a consequence of the taxpayer’s revolt that began in California and spread across the country, sharp cutbacks in federal aid to subnational levels of government, and the economic recession, state and local governments are being forced to cope with dramatically reduced resources. Nevertheless, spending for health remains big business in state and local governments today. More than one of every six dollars states spend (16.9percent) are devoted to health, slightly more than the share of the federal budget devoted to health (13 percent). Local governments spend 7.8 percent of their overall expenditures for health purposes, a proportion roughly equal to that of transportation, public safety, and natural resources and more than spending for public welfare. Recognizing that resources are shrinking at a time when responsibilities are expanding, Drew Altman and Douglas Morgan have a particular interest as officers at The Robert Wood Johnson Foundation in developing policy approaches to this difficult equation that spare the most vulnerable population segments of society. Altman, an assistant vice-president at the foundation, is a political scientist by training (Ph.D., Massachusetts Institute of Technology) and former health official in the Carter administration.Healthcare Contracts Limitations Essay  Morgan, a senior program officer at the foundation who holds a master’s degree in public administration from New York University, was formerly the City of Newark’s director of public health. Two decades ago, Altman and Morgan would have been in the forefront of the Great Society, believing as they do in a strong central government. Now, realists that they are, Altman and Morgan are struggling, along with many others, to strike new balances, build new alliances, and make tough decisions in the face of limited resources. As they underscore, these judgments will involve incremental changes rather than fundamental funding reallocations or policy shifts. Despite the incremental nature of the shifts, though, it is unlikely that ever again will state and local governments be cast so easily as the adversaries of the poor—they now represent a vast resource to people without means.

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Though responsibility for health care in the United States is, in unique fashion, both a public and private affair, in recent years, government—and most especially the federal government—has emerged as perhaps the single most important force shaping our health care system. This development has drawn attention to Washington and to what policymakers there are doing in health. Yet, as in other domestic policy areas, government’s role in health is shared. No level of government—federal, state, or local—has its own entirely autonomous sphere of action, and all three levels interact in shaping policy, in financing and delivering health care, and in running programs. Students of intergovernmental relations are familiar with Morton Grodzin’s now somewhat hackneyed metaphor for this state of affairs. The balance of government roles and responsibilities in America, he observed, looks much more like a marble cake than a layer cake with a clear separation of roles and functions. Healthcare Contracts Limitations Essay

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However, despite the current preoccupation with events in Washington, increasingly we are seeing a rediscovery of the importance of the role of state and local governments in the health care field. Whether the issue is Medicaid, hazardous wastes, chemical spills, state rate setting or certificate-of-need, homeless persons on the streets of major cities, or lead paint poisoning, more and more attention is being focused on what state and local governments are doing in health. Several developments have spurred this apparent rediscovery of the state and local role, but three appear to be most noteworthy.

First, through his New Federalism initiatives, President Reagan has stimulated a fresh debate about the respective roles of each level of government in health as well as in other fields. This so-called New Federalism would substantially reshuffle the relationship between federal-state-local government, significantly expanding the role of the states in the governance and financing of domestic programs. President Reagan’s initiative has renewed awareness of important differences between liberals and conservatives on the respective roles of federal and state government— with liberals in recent years fearful of the motivations and capacities of state government, and conservatives equally fearful of any expansion of the federal purse or presence. The fate of the Medicaid program, among others, has been a hot issue in this larger debate.Healthcare Contracts Limitations Essay

Second, these are hard times for state and local governments. The tax revolt that began with Proposition 13, recent cutbacks in federal aid, and the nationwide economic recession have placed a severe burden on state and local governments. Their fiscal plight and their efforts to cope are receiving increasing attention, much of which has concentrated on the health area where state and local governments have been grappling with the problem of how to trim expenditures while still maintaining services and programs.

Third, and perhaps most important, in a period of belt-tightening and retrenchment at all levels, both the general public and professionals in the health care field are concerned that these cutbacks might threaten the nation’s health. Over the past twenty years, this country has made truly significant gains in access to health care and in health. For example, the poor in the U.S. now see a physician and receive hospital care at least as often as the nonpoor, and such health status measures as mortality and morbidity and infant mortality have shown steady improvement. 2 Though the evidence is not yet in one year or the other, there is now concern that the cutbacks that are being made threaten these gains. It is a concern that focuses not just on Washington, where broad financing and policy decisions are made, but at the state and local level as well, where the consequences of decisions are most visible and where services are actually delivered.Healthcare Contracts Limitations Essay

Thus, for philosophical, economic, and health care reasons, the role of state and local government in health is emerging both as an issue for professionals in the field and as a significant public issue as well.

The public officials who are the object of this attention face two broad challenges. The first is how to adapt, in the short term, to federal cutbacks and the pressures of today’s economy. In today’s economic climate, what choices and tradeoffs should state and local governments make in the health area? The second challenge involves the long-term role of state and local government in health. The fundamental question is whether state and local governments should refocus what they do in the health care field. Specifically, should more resources be invested in personal medical care or in public health, and what specific investments should be made in each area? Underlying these questions are historically difficult issues involving the role of the public and private sectors in health; the role of the different levels of government; and the adequacy of our knowledge base and the capacity of our political system for making tradeoff and priority decisions of this kind. The articles that follow address these challenges as well as these underlying concerns. As background, in this article we describe where things currently stand with regard to the state and local role in health.Healthcare Contracts Limitations Essay

THE EVOLUTION OF THE STATE AND LOCAL ROLE
Broadly speaking, the health-related activities of state and local government are: traditional public health, including health monitoring, sanitation, and disease control; the financing and delivery of personal health services including Medicaid, mental health, and direct delivery through public hospitals and health departments; environmental protection, including protection against man-made environmental and occupational hazards; and the regulation of the providers of medical care through certificate-of-need and state rate setting as well as licensing and other functions. Though we will not deal with these equally or comprehensively, a selective look at the history is useful in thinking about future roles and choices.

State and local government involvement in public health began with the great epidemics of the late eighteenth and early nineteenth centuries. The first of these, the yellow fever epidemic in Philadelphia, struck in 1793, and epidemics of cholera, small pox, and yellow fever were frequent occurrences over the next fifty years. 3 Initially, government responded to these epidemics by instituting quarantine measures and efforts to improve community sanitation. Generally these were directed by physicians appointed by the city or state government. Today we know that the causes of these epidemics were in large part social and economic. Counted among them were a rapidly growing and fast moving population; the urbanization of the Eastern seaboard which resulted in overcrowding, bad housing, inadequate sanitary facilities, polluted water supplies, and contaminated food; and the rapid expansion of the West, resulting in similar conditions on a smaller scale in new Western towns and communities. 4 However, the importance of these factors was not well understood in the early nineteenth century. Even when England and other countries were beginning to address these problems effectively, government in the United States was slow to respond. Due partly to the epidemics in Philadelphia, the nation’s capitol was moved from that city to Washington, D.C. in 1800.Healthcare Contracts Limitations Essay

At the local level in the early nineteenth century, a trend towards the full-time employment of persons to serve as the functional agents of local boards of health developed. This was the first step in the formation of local health departments. Health departments were established in Baltimore (1798), Charleston (1815), Philadelphia (1818), Providence (1832), and Cambridge (1846). 5 But many cities did not establish separate public health agencies for some time. For example, New York City appointed its first inspector of health in 1804, but from 1810 to 1838 inspectors of health operated as a branch of the police department, sharing responsibility for health matters on a day-to-day basis with a state-appointed health officer (who was concerned mainly with the application of quarantine laws to vessels entering port) and a resident physician, usually a municipal official whose function was to be on the alert for cases of communicable disease within the city. 6 In 1866, New York City formally established a central administration for health activities called the Metropolitan Board of Health. 7 Other major cities —Chicago (1867), Louisville (1870), Indianapolis (1872), and Boston (1873) —did likewise. Healthcare Contracts Limitations Essay

Even with these early beginnings, public health in this nation did not begin to evolve as we know it today until the latter half of the nineteenth century. During this period two major events took place. The first was the publication of the Shattuck Report by the Massachusetts Sanitary Commission in 1850. Though today heralded as the Magna Carta of public health, the Shattuck Report was not received with enthusiasm when it first appeared on the scene. The report was authored by Lemuel Shattuck of Boston, a bookseller and publisher who had become interested in public health through his activities in developing statewide registries for vital statistics. The Shattuck Report recommended the establishment of state health departments and of local boards of health in each town. In addition, it urged sanitary surveys of particular urban communities and other localities. 9 It was not until some nineteen years later, however, that Massachusetts established its first state board of health. California followed a year later, and by the end of the century, thirty-eight other states had followed suit.Healthcare Contracts Limitations Essay

The other significant development—really a series of related developments—involved breakthroughs in the study of bacteria and the diseases they produce. By the late 1800s, the discoveries of Pasteur and others had built a foundation of knowledge and technique for advances in the following decades that led ultimately to dramatic progress in the control of infectious diseases. Armed with this new science, health authorities began to act with greater discrimination in quarantine and environmental sanitation techniques. For example, knowing the incubation period of a given disease, they had a sound basis for setting the number of days required for quarantine. Knowing the conditions under which water or food transmitted disease, they could prescribe effective measures for control of such conditions. 10

This maturation continued into the early decades of the twentieth century. Beginning in the mid-1930s, it was substantially augmented by still another important scientific development, this one brought to the public through the personal medical care system rather than through public health per se. This was the “antimicrobial revolution” and the development and subsequent use of antibiotics in the delivery of personal health services. Even though there had been a decline in the frequency of certain infectious diseases before the full effects of these different breakthroughs were felt, the downward trends were increased dramatically as a result of them. Due in part to these advances, as well as improvements in living standards, nutrition, and other factors, trends in overall mortality rates showed dramatic decreases.Healthcare Contracts Limitations Essay

State and local health departments became the major vehicles by which these advances in both microbial science and environmental sanitation were made available to the public. As state and local health departments began to direct their attention to the causes of death and morbidity, they broadened and refined their activities. Services were made available to the community at large whether people were sick or not. Programs and activities were developed to aid those who were considered at the greatest risk of contracting disease. For example, the first children’s bureau in a city health department was established in 1908 because of a conscientious and inquiring child health inspector, Josephine Baker, M.D., who was appalled at the conditions in which pregnant mothers and their newborns lived. 11

As the nation moved into the 1900s, public health departments continued to refine their activities. In 1949, the Minnesota State Department of Health became the first to employ an epidemiologist; one year later it established a division of epidemiology. 12 In 1908 there were no county health departments; by 1920 there were 131. 13 Gradually, the traditional American ambivalence about government interference gave way to a desire for the benefits that government intervention could provide to the public through sanitation, control of communicable disease, and other traditional public health activities.Healthcare Contracts Limitations Essay

At the same time, state and local governments were playing an increasingly important role in the delivery of personal health services. Beginning as poor houses more concerned with welfare than providing medical services, the almshouses of the 1700s and 1800s evolved in the late 1800s into city hospitals whose primary purpose was to deliver medical services. In the early 1900s, these hospitals affiliated with medical schools and acquired full-time staffs. 14 Over roughly the same period, the inpatient population of state mental institutions grew to a peak of 560,000 in 1955. Now, as a result of the deinstitutionalization movement of the last twenty-five years, there are today less than 150,000 people in state mental hospitals. 15 How to care properly for those who have been discharged from state institutions or are no longer admitted to them is currently a difficult and pressing policy issue.

Today, the core of our “public” delivery system is the nation’s ninety urban public hospitals owned by city or county government and forty-five state-owned university hospitals. These 135 hospitals represent roughly two-thirds of the total public hospital beds in the United States. Most of the remaining 1,770 “public” hospitals serve as essentially community hospitals and admit predominantly private patients. They tend to be smaller and located in suburban or rural areas. Combined with selected voluntary hospitals with high Medicaid and free care caseloads— usually private teaching hospitals—these 135 institutions represent the country’s true back-up delivery system for the poor. 16 Though Medicaid and Medicare did enable large numbers of the poor to purchase care from private hospitals and physicians, the size and scope of state Medicaid programs varies tremendously, and the record across the country is uneven in this regard. As a result, despite the passage of Medicaid and Medicare, in many large cities these public and selected voluntary hospitals continue to play a vital role in delivering personal health services to the poor as well as to other special population groups, including alcohol and drug abusers, victims of violence, and the chronically mentally ill. Nationally, public hospitals in the nation’s 100 largest cities provide four times as much care for the poor, as a proportion of the total care they deliver, as do private hospitals in the same cities. (See Figure 1 .) On average, care for the poor—free care, bad debt, and care for Medicaid recipients—represents almost 40 percent of what public hospitals in the largest cities do. Today, ninety public general hospitals provide 13 percent of all inpatient services and 30 percent of all outpatient visits in the 100 largest cities.Healthcare Contracts Limitations Essay

Although health outcomes have improved in low-income and middle-income countries (LMICs) in the past several decades, a new reality is at hand. Changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems to produce better health outcomes and greater social value. But staying on current trajectory will not suffice to meet these demands. What is needed are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs. Quality should not be the purview of the elite or an aspiration for some distant future; it should be the DNA of all health systems. Furthermore, the human right to health is meaningless without good quality care because health systems cannot improve health without it.
We propose that health systems be judged primarily on their impacts, including better health and its equitable distribution; on the confidence of people in their health system; and on their economic benefit, and processes of care, consisting of competent care and positive user experience. The foundations of high-quality health systems include the population and their health needs and expectations, governance of the health sector and partnerships across sectors, platforms for care delivery, workforce numbers and skills, and tools and resources, from medicines to data. In addition to strong foundations, health systems need to develop the capacity to measure and use data to learn. High-quality health systems should be informed by four values: they are for people, and they are equitable, resilient, and efficient.Healthcare Contracts Limitations Essay
For this Commission, we examined the literature, analysed surveys, and did qualitative and quantitative research to evaluate the quality of care available to people in LMICs across a range of health needs included in the Sustainable Development Goals (SDGs). We explored the ethical dimensions of high-quality care in resource-constrained settings and reviewed available measures and improvement approaches. We reached five conclusions:
The care that people receive is often inadequate, and poor-quality care is common across conditions and countries, with the most vulnerable populations faring the worst
Data from a range of countries and conditions show systematic deficits in quality of care. In LMICs, mothers and children receive less than half of recommended clinical actions in a typical preventive or curative visit, less than half of suspected cases of tuberculosis are correctly managed, and fewer than one in ten people diagnosed with major depressive disorder receive minimally adequate treatment. Diagnoses are frequently incorrect for serious conditions, such as pneumonia, myocardial infarction, and newborn asphyxia. Care can be too slow for conditions that require timely action, reducing chances of survival. At the system level, we found major gaps in safety, prevention, integration, and continuity, reflected by poor patient retention and insufficient coordination across platforms of care. One in three people across LMICs cited negative experiences with their health system in the areas of attention, respect, communication, and length of visit (visits of 5 min are common); on the extreme end of these experiences were disrespectful treatment and abuse. Quality of care is worst for vulnerable groups, including the poor, the less educated, adolescents, those with stigmatised conditions, and those at the edges of health systems, such as people in prisons.Healthcare Contracts Limitations Essay
Universal health coverage (UHC) can be a starting point for improving the quality of health systems. Improving quality should be a core component of UHC initiatives, alongside expanding coverage and financial protection. Governments should start by establishing a national quality guarantee for health services, specifying the level of competence and user experience that people can expect. To ensure that all people will benefit from improved services, expansion should prioritise the poor and their health needs from the start. Progress on UHC should be measured through effective (quality-corrected) coverage.
High-quality health systems could save over 8 million lives each year in LMICs
More than 8 million people per year in LMICs die from conditions that should be treatable by the health system. In 2015 alone, these deaths resulted in US$6 trillion in economic losses. Poor-quality care is now a bigger barrier to reducing mortality than insufficient access. 60% of deaths from conditions amenable to health care are due to poor-quality care, whereas the remaining deaths result from non-utilisation of the health system. High-quality health systems could prevent 2·5 million deaths from cardiovascular disease, 1 million newborn deaths, 900 000 deaths from tuberculosis, and half of all maternal deaths each year. Quality of care will become an even larger driver of population health as utilisation of health systems increases and as the burden of disease shifts to more complex conditions. The high mortality rates in LMICs for treatable causes, such as injuries and surgical conditions, maternal and newborn complications, cardiovascular disease, and vaccine preventable diseases, illustrate the breadth and depth of the health-care quality challenge. Poor-quality care can lead to other adverse outcomes, including unnecessary health-related suffering, persistent symptoms, loss of function, and a lack of trust and confidence in health systems. Waste of resources and catastrophic expenditures are economic side effects of poor-quality health systems. As a result of this, only one-quarter of people in LMICs believe that their health systems work well.Healthcare Contracts Limitations Essay
Health systems should measure and report what matters most to people, such as competent care, user experience, health outcomes, and confidence in the system
Measurement is key to accountability and improvement, but available measures do not capture many of the processes and outcomes that matter most to people. At the same time, data systems generate many metrics that produce inadequate insight at a substantial cost in funds and health workers’ time. For example, although inputs such as medicines and equipment are commonly counted in surveys, these are weakly related to the quality of care that people receive. Indicators such as proportion of births with skilled attendants do not reflect quality of childbirth care and might lead to false complacency about progress in maternal and newborn health.Healthcare Contracts Limitations Essay
This Commission calls for fewer, but better, measures of health system quality to be generated and used at national and subnational levels. Countries should report health system performance to the public annually by use of a dashboard of key metrics (eg, health outcomes, people’s confidence in the system, system competence, and user experience) along with measures of financial protection and equity. Robust vital registries and trustworthy routine health information systems are prerequisites for good performance assessment. Countries need agile new surveys and real-time measures of health facilities and populations that reflect the health systems of today and not those of the past. To generate and interpret data, countries need to invest in national institutions and professionals with strong quantitative and analytical skills. Global development partners can support the generation and testing of public goods for health system measurement (civil and vital registries, routine data systems, and routine health system surveys) and promote national and regional institutions and the training and mentoring of scientists.
New research is crucial for the transformation of low-quality health systems to high-quality ones
Data on care quality in LMICs do not reflect the current disease burden. In many of these countries, we know little about quality of care for respiratory diseases, cancer, mental health, injuries, and surgery, as well as the care of adolescents and elderly people. There are vast blind spots in areas such as user experience, system competence, confidence in the system, and the wellbeing of people, including patient-reported outcomes. Measuring the quality of the health system as a whole and across the care continuum is essential, but not done. Filling in these gaps will require not only better routine health information systems for monitoring, but also new research, as proposed in the research agenda of this Commission. For example, research will be needed to rigorously evaluate the effects and costs of recommended improvement approaches on health, patient experience, and financial protection. Healthcare Contracts Limitations Essay Implementation science studies can help discern the contextual factors that promote or hinder reform. New data collection and research should be explicitly designed to build national and regional research capacity.
Improving quality of care will require system-wide action
To address the scale and range of quality deficits we documented in this Commission, reforming the foundations of the health system is required. Because health systems are complex adaptive systems that function at multiple interconnected levels, fixes at the micro-level (ie, health-care provider or clinic) alone are unlikely to alter the underlying performance of the whole system. However, we found that interventions aimed at changing provider behaviour dominate the improvement field, even though many of these interventions have a modest effect on provider performance and are difficult to scale and sustain over time. Achieving high-quality health systems requires expanding the space for improvement to structural reforms that act on the foundations of the system.
This Commission endorses four universal actions to raise quality across the health system. First, health system leaders need to govern for quality by adopting a shared vision of quality care, a clear quality strategy, strong regulation, and continuous learning. Ministries of health cannot accomplish this alone and need to partner with the private sector, civil society, and sectors outside of health care, such as education, infrastructure, communication, and transport. Second, countries should redesign service delivery to maximise health outcomes rather than geographical access to services alone. Primary care could tackle a greater range of low-acuity conditions, whereas hospitals or specialised health centres should provide care for conditions, such as births, that need advanced clinical expertise or have the risk of unexpected complications. Third, countries should transform the health workforce by adopting competency-based clinical education, introducing training in ethics and respectful care, and better supporting and respecting all workers to deliver the best care possible. Fourth, governments and civil society should ignite demand for quality in the population to empower people to hold systems accountable and actively seek high-quality care. Additional targeted actions in areas such as health financing, management, district-level learning, and others can complement these efforts. What works in one setting might not work elsewhere, and improvement efforts should be adapted for local context and monitored. Funders should align their support with system-wide strategies rather than contribute to the proliferation of micro-level efforts.Healthcare Contracts Limitations Essay
In this Commission, we assert that providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical. Moving to a high-quality health system—one that improves health and generates confidence and economic benefits—is primarily a political, not technical, decision. National governments need to invest in high-quality health systems for their own people and make such systems accountable to people through legislation, education about rights, regulation, transparency, and greater public participation. Countries will know that they are on the way towards a high-quality, accountable health system when health workers and policymakers choose to receive health care in their own public institutions.

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Introduction
The past 20 years have been called a golden age for global health.1 Fuelled by a major increase in domestic health spending and donor funding, LMICs have vastly expanded access to health determinants (eg, clean water and sanitation) and health services alike (eg, vaccination, antenatal care, and HIV treatment).2, 3, 4 These expansions have saved the lives of millions of children, men, and women, largely by averting deaths from infectious diseases.5 However, these past decades were not as favourable for preventing deaths from non-communicable diseases and acute conditions, such as ischaemic heart disease, stroke, diabetes, neonatal mortality, and injuries, for which mortality stagnated or increased.6 The lowest-income countries and the poorest people within countries generally had the worst outcomes, despite considerable efforts to increase use of health care.7 The strategy that brought big wins for child health and infectious diseases will not suffice to reach the health-related SDGs. The newly ascendant health conditions, including chronic and complex conditions, require more than a single visit or standardised pill pack; they require highly skilled, longitudinal, and integrated care. Such care is also needed to address the substantial residual mortality from maternal and child conditions and infectious diseases. In short, it is becoming clear that access to health care is not enough, and that good quality of care is needed to improve outcomes. India learned this with Janani Suraksha Yojana, a cash incentive programme for facility births, which massively increased facility delivery but did not measurably reduce maternal or newborn mortality.8
High-quality care involves thorough assessment, detection of asymptomatic and co-existing conditions, accurate diagnosis, appropriate and timely treatment, referral when needed for hospital care and surgery, and the ability to follow the patient and adjust the treatment course as needed.Healthcare Contracts Limitations Essay
Health systems should also take into account the needs, experiences, and preferences of people and their right to be treated with respect.9 Although many consumer services make user experience a central mission, health systems—like other public sector systems—are often difficult to use, indifferent to the time and preferences of people, and reluctant to share decision-making processes.10 Indeed, some providers are rude and even abusive—a fundamental abrogation of human rights and health system obligations.9 At the same time, health workers might not receive the support and respect required to have a fulfilling professional life. Finally, systems can be inefficient, wasting scarce resources on unnecessary care and on low-quality clinics that people bypass, while imposing high costs on users.11
The SDG era demands new ways of thinking about health systems. Although they are only one contributor to good health—other major contributors being social determinants of health such as education, wealth, employment, and social protections, and cross-sectoral public health actions such as tobacco taxation and improved food, water, and road and occupational safety regulations12—access to high-quality health care is a human right and moral imperative for every country.13 Moreover, health systems are a powerful engine for improving survival and wellbeing and they are the focus of our report.14, 15 We endorse WHO’s definition of a health system as consisting of “all organisations, people, and actions whose primary intent is to promote, restore, or maintain health”, and we focus this Commission on the organised health sector, public and private, including community health workers.16 Although informal providers (those with little or no formal clinical training) also provide care in some countries, there are—with a few notable exceptions—insufficient data on the quality of care offered by these providers, and we do not cover them in this Commission.Healthcare Contracts Limitations Essay
Addressing quality of care is particularly pertinent as countries begin to implement UHC.17 UHC represents a substantial new investment of national resources—one that embodies new concrete commitments about the type of care that people have a right to expect. Newly transparent benefit packages can, in turn, create public expectations that governments will be under pressure to fulfil. Furthermore, new investments in health care will face scrutiny from finance ministers, who will demand efficient use of resources and better results measured in longer lifespans, restored physical and mental functions, user satisfaction, and economic productivity.
What should a high-quality health system look like in countries with resource constraints and competing health priorities that aspire to reach the SDGs? The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era, comprised of 30 academics, policy makers, and health system experts from 18 countries, seeks to answer this question.18 In this Commission, we propose new ways to define, measure, and improve the performance of health systems. We review evidence of past approaches and look for strategies that can change the trajectory of health systems in LMICs.
Our work is informed by several principles. First, the principle that health systems are for people. Health systems need to work with people not only to improve health outcomes, but also to generate non-health-related value, such as trust and economic benefit for all people, including the poor and vulnerable. Second, the principle that people should be able to receive good quality, respectful care for any health concern that can be tackled within their country’s resource capacity. Third, the principle that high-quality care should be the raison d’être of the health system, rather than a peripheral activity in ministries of health. Finally, the principle that fundamental change should be prioritised over piecemeal approaches. We recognise that health systems are complex adaptive systems that resist change and can be impervious to isolated interventions; indeed, multiple small-scale efforts can be deleterious. Quality of care is an emergent property that requires shared aims among all health system actors, favourable health system foundations, and is honed through iterative efforts to improve and learn from successes and failures. These considerations guided our analysis.Healthcare Contracts Limitations Essay
We are also aware of other major efforts on quality of care at the time of the writing of this Commission. WHO convened the Quality of Care Network to facilitate joint learning, accelerate scale-up of quality maternal, newborn, and child services, and strengthen the evidence for cost-effective approaches. WHO, the World Bank, and the Organisation for Economic Co-operation and Development (OECD) published a global report on quality of health care earlier in 2018.19 The US National Academy of Medicine has begun a study on improving the quality of health care across the globe.
There is also new interest in stronger primary care that can promote health, prevent illness, identify the sick from the healthy, and efficiently manage the needs of those with chronic disease.20 The Primary Health Care Performance Initiative, a multistakeholder effort, is focusing on measuring and comparing the functioning of primary health-care systems and identifying pathways for improvement.21 Primary care has been a main platform for provision of health care in low-income countries, but there—as elsewhere—the changing disease burden, urbanisation, and rising demand for advanced services and excellent user experience are challenging this current model of care.
Our work was substantially strengthened with input from nine National High-Quality Health Systems Commissions that were formed to explore quality of care in their local contexts alongside the global Commission. To ensure that our work reflects the needs of people and communities, we have sought input from a people’s voice advisory board and we obtained advice and policy perspectives from an external advisory council. Our intended audiences for the report are people, national leaders, health and finance ministers, policy makers, managers, providers, global partners (bilateral and multilateral institutions and foundations), advocates, civil society, and academics.Healthcare Contracts Limitations Essay
This report is arranged in the following manner: in section 1, we propose a new definition for high-quality health systems; in section 2, we describe the state of health system quality in LMICs, bringing together multiple national and cross-national data on quality of care for the first time; in section 3, we tackle the ethics of good quality of care and propose mechanisms for ensuring that the poor and vulnerable benefit from improvement; in section 4, we review the current status of quality measurements and propose how to measure better and more efficiently; in section 5, we reassess the available options for improvement and recommend new structural solutions; in section 6, we conclude with a summary of our key messages, our recommendations, and a research agenda.
We recognise that the level of ambition implied in our recommendations might be daunting to low-income countries that are struggling to put in place the basics of health care. In this Commission, we are describing a new aspiration for health systems that can guide policies and investments now. Regardless of starting point, every country has opportunities to get started on the path to high-quality health systems.
Section 1: Redefining high-quality health systems
The systematic examination of health-care quality began with the work of Avedis Donabedian, whose 1966 article22 proposed a framework for quality of care assessment that described quality along the dimensions of structure, process, and outcomes of care. At the turn of the 21st century, the Committee on Quality of Health Care in America of the Institute of Medicine (IOM) produced two influential quality reports23, 24 that galvanised the examination of quality in the US health system and prompted similar investigations in other industrialised countries. The IOM Committee defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.23 The committee noted that 21st century health systems should seek to improve performance on six dimensions of quality of care: safety, effectiveness, patient-centredness, timeliness, efficiency, and equity. The committee also observed that “the current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”23 In 2010, Michael Porter proposed25 that health systems be fundamentally accountable for producing value, which should be defined around the user. International organisations, such as WHO, and many low-income and high-income countries have relied on the IOM definition of quality and its core dimensions. WHO has also separately defined integrated people-centred health systems as systems where “all people have equal access to quality health services that are coproduced in a way that meets their life course needs”.26  Healthcare Contracts Limitations Essay
Building on this and other work, this section sets out our rationale for an updated definition of high-quality health systems and a conceptual framework ready for the health challenges, patient expectations, and rising ambitions of today.27, 28
The improvement of health outcomes is the sine qua non of health systems; these outcomes include longer lives, better quality of life, and improved capacity to function. In addition to better health, people derive security and confidence from having a trusted source of care when illness renders them most vulnerable. In this way, health systems also function as key social institutions, both deriving from and shaping social norms and able to promote or corrode public trust.29, 30 Finally, health systems cannot be static and must adapt to changing societal needs. This Commission defines a high-quality health system as the following:
A high-quality health system is one that optimises health care in a given context by consistently delivering care that improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs.
Context is paramount in this definition; health systems have been shaped by different histories and, as a result, function differently across LMICs.
High-quality health systems are underpinned by four values: high-quality health systems are for people and are equitable, resilient, and efficient. A focus on people begins with the self-evident observation that health systems must reach people—access is a prerequisite for benefiting from health care. However, this focus also signifies that people are not just beneficiaries of health services, but have a right to health care and have agency over their health and health-care decisions. Therefore, people become accountability agents, able to hold health system actors to account. The emphasis on people-centredness is especially crucial in health care because of the asymmetry of power and information between provider and patient. The focus on people works not only as a moral imperative to protect against the adverse effects of this power imbalance, but also as a corrective action that reduces the imbalance through patient empowerment and better accountability. Health systems must also treat well the people that work within them, who deserve a supportive work environment (safe working conditions, efficient and supportive management, and appropriate role assignment) and are themselves health-care users. Demotivated providers cannot contribute to a high-quality health system.
A focus on equity means that high-quality health care needs to be available and affordable for all people, regardless of underlying social disadvantages. Measures of quality need to be disaggregated by stratifiers of social power—such as wealth, gender, or ethnicity—and quality improvements should explicitly include poor and vulnerable people to redress existing inequities.Healthcare Contracts Limitations Essay
Health systems in LMICs have been slow to change from their legacy functions focused on infectious diseases and maternal and child health, but health needs and expectations are shifting, sometimes quickly. Health crises, such as the Ebola epidemic, acutely illustrate the need for resilient systems, defined as systems that can prepare for and effectively respond to crises while maintaining core functions and reorganising if needed.31 High-quality health systems also need everyday resilience to respond to routine challenges, and this requires accountable leaders who respect and motivate their front-line staff.32
Lastly, health systems must be efficient: although spending on health systems is tightly associated with income and therefore varies greatly across LMICs, all health systems should aim to avoid waste and achieve the maximum possible improvement in health outcomes with the investment received.
We propose a new conceptual framework for high-quality health systems with three key domains: foundations, processes of care, and quality impacts (figure 1). This framework stems from our definition of high-quality health systems and is informed by past frameworks in the fields of health systems and quality improvement, including Donabedian’s framework,22 WHO’s building blocks16 and maternal quality of care27 frameworks, Judith Bruce’s family planning quality framework,28 Getting Health Reform Right,33 the Juran trilogy, and the Deming quality cycle. Healthcare Contracts Limitations Essay