====== Health care reform ======


[[Health care]] reform- is for the most part, governmental policy that affects health care delivery in a given place. Health care reform typically attempts to:

Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies

Expand the array of health care providers consumers may choose among

Improve the access to health care specialists

Improve the quality of health care

Give more care to citizens

Decrease the cost of health care

Modern [[health care reform]]s focus on identifying and measuring the [[quality]] and [[value]] of [[care]]. 
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In a [[healthcare]] landscape in which [[cost]]s increasingly matter, Salas-Vega et al. sought to distinguish among the clinical and nonclinical drivers of patient [[length of stay]] (LOS) in the [[hospital]] following elective [[lumbar laminectomy]]-a common spinal surgery that may be reimbursed using bundled payments-and to understand their relationships with [[patient outcome]]s and costs.

Patients ≥ 18 years of age undergoing [[laminectomy]] surgery for degenerative [[lumbar spinal stenosis]] within the Cleveland Clinic health system between March 1, 2016, and February 1, 2019, were included in this analysis. Generalized linear modeling was used to assess the relationships between the day of surgery, patient [[discharge]] disposition, and hospital LOS, while adjusting for underlying patient health risks and other nonclinical factors, including the hospital surgery site and health insurance.

A total of 1359 eligible patients were included in the authors' analysis. The mean LOS ranged between 2.01 and 2.47 days for Monday and Friday cases, respectively. The LOS was also notably longer for patients who were ultimately discharged to a [[skilled nursing facility]] (SNF) or rehabilitation center. A prolonged LOS occurring later in the week was not associated with greater underlying health risks, yet it nevertheless resulted in greater costs of care: the average total surgical costs for lumbar laminectomy were 20% greater for Friday cases than for Monday cases, and 24% greater for late-week cases than for early-week cases ultimately transferred to SNFs or rehabilitation centers. A Poisson generalized linear model fit the data best and showed that the comorbidity burden, surgery at a tertiary care center versus a community hospital, and the incidence of any postoperative complication were associated with significantly longer hospital stays. Discharge to home healthcare, SNFs, or rehabilitation centers, and late-week surgery were significant nonclinical predictors of LOS prolongation, even after adjusting for underlying patient health risks and insurance, with LOSs that were, for instance, 1.55 and 1.61 times longer for patients undergoing their procedure on Thursday and Friday compared to Monday, respectively.

Late-week surgeries are associated with a prolonged LOS, particularly when discharge is to an SNF or [[rehabilitation]] center. These findings point to opportunities to lower [[cost]]s and improve [[outcome]]s associated with elective surgical care. [[Intervention]]s to optimize surgical scheduling and [[perioperative]] [[care]] coordination could help reduce prolonged LOSs, lower costs, and, ultimately, give service line management personnel greater flexibility over how to use existing [[resource]]s as they remain ahead of [[health care reform]]s
((Salas-Vega S, Chakravarthy VB, Winkelman RD, Grabowski MM, Habboub G, Savage JW, Steinmetz MP, Mroz TE. Late-week surgery and discharge to specialty care associated with higher costs and longer lengths of stay after elective lumbar laminectomy. J Neurosurg Spine. 2021 Apr 6:1-7. doi: 10.3171/2020.11.SPINE201403. Epub ahead of print. PMID: 33823491.)).
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Patient satisfaction is particularly important in the management of degenerative cervical radiculopathy (DCR) since it leads to significant neck pain and disability primarily affecting the patients' quality of life.

To determine the association of baseline and 12-mo Neck Disability Index (NDI) with patient satisfaction after elective surgery for DCR.

The Quality Outcomes Database cervical module was queried for patients who underwent elective surgery for DCR. A multivariable proportional odds regression model was fitted with 12-mo satisfaction as the outcome. The covariates for this model included patients' demographics, surgical characteristics, and baseline and 12-mo patient reported outcomes (PROs). Wald-statistics were calculated to determine the relative importance of each independent variable for 12-mo patient satisfaction.

The analysis included 2206 patients who underwent elective surgery for DCR. In multivariable analysis, after adjusting for baseline and surgery specific variables, the 12-mo NDI score showed the highest association with 12-mo satisfaction (Waldχ2-df = 99.17, 58.1% of total χ2). The level of satisfaction increases with decrease in 12-mo NDI score regardless of the baseline NDI score.

The study identifies 12-mo NDI score as a very influential driver of 12-mo patient satisfaction after surgery for DCR. In addition, there are lesser contributions from other 12-mo PROs, baseline Numeric Rating Scale for arm pain and American Society of Anesthesiologists (ASA) grade. The baseline level of disability was found to be irrelevant to patients. They seemed to only value their current level of disability, compared to baseline, in rating satisfaction with surgical outcome
((Khan I, Sivaganesan A, Archer KR, Bydon M, McGirt MJ, Nian H, Harrell FE,
Foley KT, Mummaneni PV, Bisson EF, Shaffrey C, Harbaugh R, Asher AL, Devin CJ;
QOD Vanguard Sites . Does Neck Disability Index Correlate With 12-Month
Satisfaction After Elective Surgery for Cervical Radiculopathy? Results From a
National Spine Registry. Neurosurgery. 2019 Jul 3. pii: nyz231. doi:
10.1093/neuros/nyz231. [Epub ahead of print] PubMed PMID: 31268151.
)).
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[[Ethical]] discussions around [[health care reform]] typically focus on problems of social justice and [[health care]]equity. 

A review, in contrast, focuses on ethical issues of particular importance to neurosurgeons, especially with respect to potential changes in the physician-patient relationship that may occur in the context of health care reform.

The Patient Protection and Affordable Care Act (ACA) of 2010 (H.R. 3590) was not the first attempt at health care reform in the United States but it is the one currently in force. Its ambitions include universal access to health care, a focus on population health, payment reform, and cost control. Each of these aims is complicated by a number of ethical challenges, of which 7 stand out because of their potential influence on patient care: the accountability of physicians and surgeons to individual patients; the effects of financial incentives on clinical judgment; the definition and management of conflicting interests; the duty to preserve patient autonomy in the face of protocolized care; problems in information exchange and communication; issues related to [[electronic health record]]s and [[data security]]; and the appropriate use of "Big Data."Systematic social and economic reforms inevitably raise ethical concerns. While the ACA may have driven these 7 to particular prominence, they are actually generic. Nevertheless, they are immediately relevant to the practice of neurosurgery and likely to reflect the realities the profession will be obliged to confront in the pursuit of more efficient and more effective health care
((Dagi TF. Seven Ethical Issues Affecting Neurosurgeons in the Context of Health
Care Reform. Neurosurgery. 2017 Apr 1;80(4S):S83-S91. doi: 10.1093/neuros/nyx017.
PubMed PMID: 28375501.
)).