The American Heart Association’s 2008 Statement of Principles for Healthcare Reform
2008; Lippincott Williams & Wilkins; Volume: 118; Issue: 21 Linguagem: Inglês
10.1161/circulationaha.108.191092
ISSN1524-4539
AutoresRaymond J. Gibbons, Daniel W. Jones, Timothy J. Gardner, Larry B. Goldstein, James H. Moller, Clyde W. Yancy,
Tópico(s)Health Systems, Economic Evaluations, Quality of Life
ResumoHomeCirculationVol. 118, No. 21The American Heart Association's 2008 Statement of Principles for Healthcare Reform Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBThe American Heart Association's 2008 Statement of Principles for Healthcare Reform Raymond J. Gibbons, MD, FAHA, Daniel W. Jones, MD, FAHA, Timothy J. Gardner, MD, FAHA, Larry B. Goldstein, MD, FAHA, James H. Moller, MD, FAHA and Clyde W. Yancy, MD, FAHA Raymond J. GibbonsRaymond J. Gibbons , Daniel W. JonesDaniel W. Jones , Timothy J. GardnerTimothy J. Gardner , Larry B. GoldsteinLarry B. Goldstein , James H. MollerJames H. Moller and Clyde W. YancyClyde W. Yancy Originally published26 Sep 2008https://doi.org/10.1161/CIRCULATIONAHA.108.191092Circulation. 2008;118:2209–2218Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 26, 2008: Previous Version 1 Building healthier lives, free of cardiovascular diseases and stroke" is the mission of the American Heart Association (AHA). The AHA realizes that the current healthcare crisis in the United States threatens this mission. Thus, we have prepared this statement regarding healthcare reform with particular emphasis on cardiovascular diseases and stroke. We intend to promote and actively engage in a dialogue within the country that addresses these critical issues.There is an urgent need to reform our healthcare system to improve the lives of individuals who have (or who are at risk for developing) cardiovascular diseases and stroke. Nearly 15 years have passed since healthcare reform became a prominent national policy issue. In 1993 and 1994, a series of articles appeared in Circulation describing the principles, recommendations and concerns of the AHA regarding healthcare reform.1–6Tremendous accomplishments have been made over the intervening years in the biological and clinical sciences, resulting in significant improvements in the prevention, diagnosis and treatment of cardiovascular diseases and stroke. Unfortunately, new challenges threaten to reverse these gains, including the aging of the population and unwise lifestyle choices related to smoking, diet and physical activity. Children with congenital heart disease, who formerly would have died, now survive to confront these challenges. Barriers—often arising from the cost of care in the current healthcare system—make the delivery of patient-centered health care increasingly difficult. Many patients cannot readily access high-quality, evidence-based healthcare services, and healthcare providers face similar difficulties when trying to deliver these services.With over 46 million uninsured individuals in the United States and continued increases in the cost of both health insurance and health care, the need for meaningful healthcare reform is much greater today than it was 15 years ago. Unfortunately, the 46 million uninsured individuals include over 8 million children who have limited access to health care simply because their parents are uninsured.7This paper presents the AHA's current, updated principles and recommendations for healthcare reform, considering the important scientific advances that have occurred over the past 15 years, the evolution of the healthcare delivery system, and most importantly, the needs of individuals of all ages with or at risk for cardiovascular disease and stroke.BackgroundAs the nation's oldest and largest voluntary health organization dedicated to reducing death and disability from cardiovascular diseases and stroke, the AHA has focused its efforts on achieving healthcare reform that serves the best interests of patients. The AHA's vision for healthcare reform describes the changes needed to make the healthcare system work for every American, including: improving patient access to affordable health care and coverage; addressing healthcare disparities that limit the equitable delivery of health care; organizing healthcare delivery systems to ensure the highest quality and most efficient care; educating and empowering patients with relevant and contemporary information; supporting the workforce needed for both healthcare delivery and research; and investing sufficiently in biomedical research. The full range of evidence-based healthcare services, including prevention and treatment, must be readily available to all who can benefit from them.To realize the AHA's mission of "building healthier lives free of cardiovascular diseases and stroke," the AHA has invested nearly $3 billion in research over the past 60 years to advance scientific knowledge regarding the prevention and treatment of cardiovascular diseases and stroke. This research has included a broad range of efforts in the basic and clinical sciences, healthcare delivery and patient outcomes, involving all forms of congenital and acquired cardiovascular diseases and stroke.The AHA also has worked tirelessly to promote the application of research findings to the daily lives of individuals with, or at risk for, cardiovascular diseases and stroke, and to take our message into homes, schools and the workplace. The development of clinical practice guidelines, the creation of quality improvement programs that foster adherence to these guidelines, and the dissemination of public and patient education programs and materials have been vital components of the AHA's strategy. The AHA has endeavored to educate policy makers at the federal, state and local levels in its efforts to modify public policy and to improve clinical outcomes for individuals with cardiovascular diseases and stroke.The Burden of Cardiovascular Diseases and Stroke in the United StatesAlthough the death rates for cardiovascular diseases (including coronary heart disease and heart failure) and stroke have declined, these diseases remain the leading causes of death in the United States. Nearly 2400 Americans die of cardiovascular diseases or stroke each day—an average of one death every 37 seconds. In the aggregate, cardiovascular diseases and stroke claim approximately as many lives each year as cancer, chronic lower respiratory disease, accidents and diabetes mellitus combined.8Although the age-adjusted mortality rates are improving, the number of individuals with various forms of cardiovascular diseases and stroke is staggering. Nearly one in three adults in the United States have hypertension, 16 million have coronary heart disease, 5 million have heart failure, and 5.8 million are stroke survivors. In addition, each year approximately 780 000 Americans experience a new or recurrent stroke, 770 000 have a new myocardial infarction, 430 000 have a recurrent myocardial infarction, and 660 000 have newly diagnosed congestive heart failure. Approximately 36 000 infants are born each year with congenital heart defects, many requiring medical and surgical intervention.8 These children are now surviving into adulthood and face the additional burden of acquired heart disease.In 1999, the AHA established a 10-year goal to reduce the death rates and risk factors for coronary heart disease and stroke by 25 percent by 2010. At the beginning of 2008, the AHA reported success—2 years ahead of schedule—in achieving the targeted reductions in the death rates for coronary heart disease. More recently, the target for stroke was also achieved. Multiple factors drove this success, including scientific discoveries made through research, advances in clinical interventions, adoption of prevention strategies, improvements in patient education and increasingly sophisticated implementation of new scientific knowledge into day-to-day medical practice.Nonetheless, much work remains as the risks for and consequences of cardiovascular diseases and stroke remain alarmingly high. A growing epidemic of obesity and diabetes (in both children and adults) threatens to reverse many of the gains that have been achieved in reducing the adverse impacts of cardiovascular diseases and stroke.9,10 In addition, the burden of cardiovascular diseases and stroke in the United States is projected to increase significantly with the aging of the baby boomers, defined as individuals born between 1946 and 1964. For example, death rates due to cardiovascular diseases are projected to increase 2.5 times faster than the growth of the population, and the prevalence of heart diseases is projected to increase by 16 percent per decade.11 Deaths due to ischemic stroke (the most common form of stroke) are projected to increase by nearly 100 percent from 2000 to 2032.12Unmanaged Risk Factors, Healthcare Services and CostsCardiovascular diseases and stroke have a significant impact on the utilization of healthcare services and the associated costs. In 2005, there were more than 4 million visits to emergency departments and more than 6.7 million outpatient department visits with a primary diagnosis of cardiovascular diseases and stroke. Approximately 1 of every 6 hospital stays resulted from these diseases, and more than 81 million physician office visits were for a primary diagnosis of one of these conditions.8The total direct and indirect cost for cardiovascular diseases and stroke in 2008 is estimated to exceed $448 billion. One fourth of the aggregate cost of hospital care in the United States is for these conditions. In 2005, coronary atherosclerosis resulted in more than $44 billion in expenses, acute myocardial infarction hospital charges totaled $31 billion and congestive heart failure expenses equaled $29 billion.8 The net cost of congenital heart disease is difficult to estimate, but includes the societal impact of premature death.A sizable portion of cardiovascular diseases and stroke is preventable.13 Despite the opportunities for effective prevention, cardiovascular risk factor management remains inadequate. For example, more than 20 percent of the population continues to smoke, and nearly two-thirds of adults with hypertension have blood pressure that is not adequately controlled.8 Similarly, of those individuals who meet the evidence-based guidelines for lipid-lowering treatment to reduce the risk of coronary heart disease, less than half are receiving therapy. As a result, less than 20 percent of patients with coronary heart disease have achieved the targeted level for low-density lipoprotein (LDL).14 Furthermore, only approximately half of the suitable patients with atrial fibrillation receive appropriate medical treatment (anticoagulation) to prevent stroke.15Although primordial prevention and primary prevention are the best ways to protect the health of Americans of all ages and potentially ease the economic burden of cardiovascular diseases and stroke, many effective prevention strategies and programs are not being implemented for lack of federal, state and private sector investment in these efforts. Our current system is reactive instead of proactive, and as a result, we treat disease much more avidly than we prevent disease. For example, in 2007, the Centers for Disease Control and Prevention (CDC) funded 33 states and the District of Columbia to implement programs to reduce risk factors for heart disease and stroke, improve emergency response and quality care, and end treatment disparities. Thus, 17 states did not receive any funding from the CDC in 2007 either to plan or implement cardiovascular prevention programs,16 and only a few states have appropriated funds to support these important initiatives.Lack of Health InsuranceThe burden of cardiovascular diseases and stroke can be particularly problematic for individuals without health insurance. Adults with cardiovascular diseases and stroke who are uninsured have difficulty affording health care. Data derived from an AHA-commissioned analysis of the National Health Interview Survey (which included underinsured and uninsured patients) demonstrate that more than one-third of the uninsured with cardiovascular diseases and stroke (34.2 percent) reported not getting needed health care due to the cost—almost 5 times the share of the insured reporting cost as a barrier to needed care (7.3 percent). Similarly, the uninsured with cardiovascular diseases and stroke were almost 4 times as likely as their insured counterparts to report postponing healthcare services due to cost (10.3 percent versus 3.84 percent) and being unable to afford prescription drugs (37.5 percent versus 10.2 percent).17Other studies show that in comparison to people with heart diseases and stroke who have insurance, the uninsured with heart diseases and stroke experience higher mortality rates,18–20 poorer blood pressure control,21 greater neurologic impairments and longer lengths of hospital stay after stroke,18 as well as a lower likelihood of taking appropriate medications.22In today's complex healthcare environment, even individuals with health insurance can find it difficult to access medically necessary healthcare services due to rising insurance premiums, significant deductible and copayment requirements, insurance restrictions (such as limitations in access to rehabilitative services, exclusions for preexisting conditions and caps on lifetime benefits) and other insurance practices that favor low-risk enrollees over individuals with or at risk for developing chronic disease. In addition, the fragmented nature of the healthcare delivery system and the lack of coordination of healthcare services often create challenges for all patients with chronic illness, including those with cardiovascular diseases and stroke. For the millions of individuals in the United States with cardiovascular diseases and stroke who do not have healthcare insurance, the challenges are even greater.A Patient-Centered Approach to Healthcare ReformThe AHA has a longstanding commitment to approaching healthcare reform from the perspective of the patient. This focus—including the important roles that healthcare providers, biomedical research and the healthcare delivery system play in promoting the interests of individual patients—is reflected in AHA's past and current positions on healthcare reform.The AHA's Initial Principles Established in the Early 1990sIn 1992, the AHA's Board of Directors approved 5 principles for access to health care. Listed below, these principles focused on patient access to preventive services and quality health care, as well as the pursuit of ongoing biomedical research to improve the prevention and treatment of cardiovascular diseases and stroke: All United States residents should have access to quality medical care;Universal coverage for basic medical care should be available;Coverage of preventive care must be part of any proposal for healthcare access;Funds must be allocated for biomedical research, research training and clinical training; andThe AHA should participate in the development of guidelines for appropriate patient care and should support research into methods for measuring quality, outcomes and cost-effectiveness.1Fifteen years later, some progress on these 5 principles has been made—primarily with regard to the development of guidelines for appropriate patient care and for developing methods to measure quality, evaluate outcomes and determine cost-effectiveness. Progress on the remaining principles, however, has been minimal, and as a result, health care in this country is not optimal. More Americans than ever lack health insurance, presenting a major barrier to accessing quality health care. After an initial doubling, the NIH research budget has been flat with an actual reduction in purchasing power because funding has failed to keep pace with biomedical research inflation.The AHA's Principles for Healthcare Reform: 2008 and BeyondIn the context of the AHA's past stated principles, we now update what we believe to be the critical principles that must be addressed if health care in the United States is to be effective, equitable and excellent. All residents of the United States should have meaningful, affordable healthcare coverage;Preventive benefits should be an essential component of meaningful healthcare coverage, and incentives should be built into the healthcare system to promote appropriate preventive health strategies;All residents of the United States should receive affordable, high quality health care;Race, gender and geographic disparities in health care must be eliminated;Support of biomedical and health services research should be a national priority, and inflation-adjusted funding for the National Institutes of Health must be maintained and expanded; andThe United States' healthcare workforce should continue to grow and diversify through a sustained and substantial national commitment to medical education and clinical training.Principle 1: All residents of the United States should have meaningful, affordable healthcare coverageEvery individual should have affordable healthcare coverage that provides access to appropriate healthcare services and that guarantees protection from extraordinary or catastrophic medical costs. Such coverage must guarantee equitable and sustained medical care for individuals with chronic disease.DiscussionOver the past decade, there has been a significant increase in both the number and percentage of Americans without healthcare insurance, including individuals with cardiovascular disease and stroke. At the same time, a growing number of people with healthcare insurance coverage are underinsured, meaning that their healthcare insurance does not provide adequate financial protection when they are sick.Numerous studies have documented the detrimental health effects of being uninsured on individuals with heart diseases and stroke. For example, people who lack health insurance experience a 24-to-56 percent higher risk of death from stroke than those who are insured.18 A 12-year study of over 7000 Americans shows that individuals without health insurance experience a dramatic improvement in health when they become eligible for healthcare coverage through Medicare at age 65. The impact of gaining healthcare coverage is greatest for those with a history of heart disease, stroke, high blood pressure or diabetes.23One measure of underinsurance is the financial burden of health care, or the share of family income needed to pay for health care. A recent federal study indicated that in 2004, 45 million Americans—almost 18 percent—belonged to families that spent more than 10 percent of their income on health care. Those with high financial burdens were also more likely to have problems accessing healthcare services and to have foregone needed healthcare services due to the cost.24In the current healthcare system, individuals with chronic diseases such as heart diseases and stroke can face numerous challenges obtaining comprehensive, affordable healthcare coverage, often being denied coverage or charged higher premiums for a preexisiting condition. For example, young people with congenital heart defects whose age renders them ineligible for their parents' health insurance are often unable to obtain coverage because of their risk profile. Rather than continue to allow people with chronic diseases to become uninsured or underinsured, successful healthcare reform must address these insurability practices and create a fair and equitable system that does not discriminate against individuals with chronic diseases. Investment in quality healthcare services will yield dividends for individuals and society.The cost of meaningful, affordable healthcare coverage for all Americans is considerable, and the rising expenditures on publicly funded health care threatens our country's future financial health. However, this problem is not insurmountable, and the AHA believes that the initiation of a meaningful dialogue among the major stakeholders to resolve this problem in a cost-sensitive manner must be given our country's highest priority.Principle 2: Preventive benefits should be an essential component of meaningful healthcare coverage, and incentives should be built into the healthcare system to promote appropriate preventive health strategiesAll public and private sector health insurance benefits' packages should provide for the identification, monitoring and treatment of risk factors that lead to cardiovascular diseases and stroke in patients of all ages. These primordial, primary and secondary preventive benefits should be based on the AHA's scientific guidelines, the US Preventative Services Task Force recommendations and the findings of other authoritative, nationally recognized clinical consensus bodies. At a minimum, the coverage of preventive benefits should include monitoring of blood pressure, cholesterol and blood glucose levels, as well as assessment of smoking, nutrition and physical activity. Healthcare reform initiatives should also be coupled with public health interventions to promote community-based prevention of obesity and other cardiovascular risk factors.DiscussionCardiovascular diseases and stroke exact an enormous financial toll on the nation and have devastating and long-term consequences for millions of individuals and families. However, many risk factors for heart diseases and stroke are well known. Effective prevention strategies that are implemented early and followed over the long-term can mitigate the tremendous burden of cardiovascular diseases and stroke.Missed opportunities in prevention are numerous. Blood pressure is elevated in 69 percent of people who have a first heart attack, 77 percent who have a first stroke; 74 percent of individuals who have congestive heart failure have blood pressure that is higher than the clinically recommended standard. One-hundred-six million Americans have elevated total cholesterol levels.8 One third of people with diabetes—a major risk factor for cardiovascular diseases and stroke—are unaware of their disease status.25The risk factors for cardiovascular disease and stroke can develop early in life, and there is a growing epidemic of childhood obesity in the United States. The prevalence of children who are overweight tripled between 1980 and 2000. In 2000, an estimated 9 million children and adolescents ages 6 through 19 were overweight.8Healthcare coverage for preventive services that can identify risk early and allow for timely intervention varies among insurers. Healthcare coverage should consistently include evidence-based risk identification, monitoring and management services supported by the best available science. Efforts to reform healthcare insurance coverage should be coupled with public health interventions that address primordial prevention and provide community-based solutions to minimize the burden of cardiovascular diseases and stroke in all age categories.Cost-sharing for preventive services also can present challenges to those patients with or at risk for chronic illness. Recently, some employers have lowered or removed cost sharing for certain preventive benefits and the interventions used to reduce identified risks (eg, prescription drugs used to treat high blood pressure, high cholesterol and diabetes). In these purchasers' assessments, an investment in the control of risk factors is a strategic way to reduce the serious and costly consequences of heart attacks, strokes and other cardiovascular diseases. Such efforts should be encouraged and provide a valuable model for consideration during the healthcare reform debate.Principle 3: All residents of the United States should receive affordable, high quality health careHealthcare reform should promote improvements in, and evaluation of, the quality of care delivered, including adherence to clinical practice guidelines and education efforts to help consumers evaluate healthcare quality. Reform initiatives should be designed to improve the value of care delivered, minimize unnecessary interventions and treatment, and ensure that individuals always receive appropriate care that is delivered both safely and efficiently.DiscussionIn its landmark report, Crossing the Quality Chasm, the Institute of Medicine (IOM) declared that, "Between the health care we have and the care we could have lies not just a gap, but a chasm."26 In fact, Americans only receive the care recommended by best practice guidelines approximately half of the time.27To improve healthcare quality, the AHA develops clinical practice guidelines that translate clinical evidence into specific written recommendations to inform healthcare provider decision-making. The AHA integrates these practice guidelines into continuous quality improvement tools for both healthcare providers and consumers to use when evaluating healthcare choices. The increasing sophistication of these tools and the pace of advances in health information technology provide a glimpse of the role that healthcare reform could play in promoting informed clinical decision-making.The AHA also works closely with the healthcare community to report and assess quality through the development of performance measures that are integrated into quality improvement tools. This work has demonstrated the importance of evaluating quality using measures that are risk-adjusted, standardized and evidence-based.28 Quality-of-care measures can help create learning environments for healthcare professionals and ensure that best practices are applied uniformly to all patients. These measures should be broad in scope, and include measures of patient satisfaction, access and convenience to promote care that is truly patient centered.Increasing healthcare costs and research on variations in how care is delivered have led research and policy organizations to focus on the value of healthcare services and assess quality measures in conjunction with indicators of service utilization and cost. The 2008 Dartmouth Atlas of Health Care: Tracking the Care of Patients with Severe Chronic Illness found that the Medicare program spends considerably more in some regions of the country for care that is no better, and in some cases slightly worse, than care delivered in other areas of the country. A comparison of health outcomes following acute myocardial infarction and other serious conditions between higher spending and lower spending regions found mortality over a period of up to 5 years to be slightly greater in higher spending regions following acute myocardial infarction and other serious illnesses. Patients in higher spending regions also reported poorer access to care and greater waiting times.29 Outcomes were, therefore, slightly worse where more money was spent.This counterintuitive result is, in part, a consequence of the current inappropriate financial incentives under Medicare in which an increase in the amount of delivered services results in more payment, regardless of whether the services are truly needed or of benefit to the patient. These regional disparities in the volume of services have enormous fiscal consequences. Researchers estimate that nearly 30 percent of Medicare's costs could be saved without affecting health outcomes if spending in the high- and medium-cost areas of the country were reduced to spending levels in benchmark, low-cost areas.29Cost-effectiveness metrics need to be integrated within the healthcare delivery system. Healthcare reform initiatives should consider mechanisms for better aligning payment with the goal of improving healthcare quality. Programs that use specific financial incentives to promote quality, known as pay-for-performance programs, are increasingly being adopted as a means of addressing variations in healthcare quality. Although the goal of pay-for-performance programs should be to improve patient outcomes, to date, there is limited evidence of the impact of this strategy. Pay-for-performance proposals, therefore, should be considered carefully and should include evaluation mechanisms to assess their impact on patients and patient care.28 These and other potential mechanisms for financing healthcare reform should continue to be tested to measure the impact on outcomes and costs and to ensure that there are no unintended consequences.Principle 4: Race, gender and geographic disparities in health care must be eliminatedTo address disparities in care, healthcare reform proposals should, at a minimum, encourage monitoring, reporting and evaluation of data regarding the consistency and equity of healthcare delivery. Standardized, evidence-based quality measures should be used for this purpose. In addition, healthcare reform initiatives should promote cultural competency training for healthcare professionals and health literacy education for all consumers, particularly vulnerable populations.DiscussionCompared to whites, African Americans have 2 to 3 times the likelihood of dying from cardiovascular diseases or stroke at any given age.30 Studies also have shown disparities in heart disease and stroke risk factor management, such as blood pressure control, lipid level management and the treatment of diabetes and obesity.8,31Disparities in healthcare delivery play some part in these outcomes. In its 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the IOM noted that, "studies of racial and ethnic differences in cardiovascular care provide some of the most convincing evidence of healthcare disparities." In addition, the IOM noted that racial disparities in coronary revascularization procedures are associated with higher mortality among African Americans.32The presence of disparities in health care has been recognized for more than 20 years. The groundbreaking 1985 report of the US Secretary of Health and Human Services' Task Force on Black and Minority Health found that between 1979 and 1981, there were nearly 60 000 more deaths i
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