The portion of President Barack Obama’s health care law aimed at lowering the number of uninsured in the country has largely rolled out, leaving the administration increasingly turning its attention to another goal of the Affordable Care Act: controlling health care costs. It doesn’t appear, however, that the proposals will make a significant dent in government spending, and questions remain over whether providers – particularly hospitals – could see any benefit from the initiatives.

In recent months, Obama and Sylvia Burwell, the secretary for Health and Human Services, have touted a move toward payment models that reward better quality of care, rather than the current model that compensates health care providers for the number of medical services they provide.

“The message is: ‘We are going to pay you less to do more,'” Dr. Kavita Patel, managing director of clinical transformation at the Brookings Institution’s Center for Health Policy, says of the planned measures.

The government has been testing several initiatives aimed at slowing or reducing health care spending, which grows faster than the rest of the economy and makes up one-fifth of the country’s expenditures. By 2018, the administration plans to place half of payments on Medicare – the government’s program for adults 65 and older – under new models.

Attempts at changing payment models in the past, however, have yielded only modest savings at best. Also, what remains unclear is why hospitals would buy into a payment system voluntarily that likely would reduce their bottom lines.

“The answer is: They wouldn’t,” says Gerard Anderson, director of the Center for Hospital Finance and Management at the Johns Hopkins Bloomberg School of Public Health.

Hospitals do participate in different payment models, he says, so they can be prepared if there is a change in the way payments are delivered.

Katherine Hayes, director of health policy at the Bipartisan Policy Center, says that for many hospitals, the move is in part altruistic. “It’s based on the philosophy of the hospital and who the key leaders are,” she says. “There are those who are committed to improving care and lowering costs.”

Changing how health care is paid for is considered necessary for the country’s economic stability. Though recent data have shown that the growth in health care spending has slowed – a trend economists largely attribute to lingering results from the Great Recession – there is no guarantee the trend will stick.

Because of the Affordable Care Act, which requires Americans to buy insurance or pay a penalty, the number of uninsured has dropped by a third, while the number of people enrolling in public insurance is growing. When combined with the Children’s Health Insurance Program, Medicaid – the government’s program for low-income Americans – reached 70 million in enrollment last year, after the government expanded eligibility under the health care law.

Medicare, for its part, is projected to grow as the baby boomer generation ages into it. It is likely to reach more than 80 million enrollees by 2050. Already, government figures show that in 2013, spending on the program neared $600 billion, accounting for 14 percent of the federal budget.

Mounting health care costs may be dire news for the U.S. deficit, but they have been a boon for hospitals, whose share of health care costs, despite shrinking in recent years, is larger than that of other parts of the health care industry. The current fee-for-service model works well for hospitals’ business: The more procedures and tests they do, the more reimbursement they can collect.

Patel says hospitals are experimenting to see whether they can change their business models. A hospital that becomes more efficient with Medicare patients, for instance, can make up the difference in income by taking in a higher volume of patients, some of whom might have commercial insurance.

Still, she adds: “They were happy with [fee-for-service] because they make money off it.”

But hospitals that don’t adopt new payment models risk not being able to compete. “A lot of areas are doing well in fee-for-service care … and aren’t interested in alternative payment
models,” Hayes says. But when other hospitals in the area are using them, there is pressure to do the same, she points out.

“Some may wait too long and may not be able to get key providers, like surgeons, in their network,” she says. “Those who succeed will get a higher percentage of patients in the community than those who don’t take this on.”

There likely are several ways to reduce costs while still improving outcomes, experts say. In 2012, the Institute of Medicine found that a third of health care spending, or $785 billion, is wasted on unnecessary care, including repeated tests, or unneeded procedures that don’t make people better, but could even hurt them.

One type of payment system in the spotlight the accountable care organization model, which reward doctors and hospitals for saving money and for improving the health care of their patients. Hospitals are given a price limit, and if they stay under it, they get to keep a certain amount of the savings they incur.

The American Hospital Association says it is open to trying new models of payment delivery. “Members are enthusiastic about accountable care organizations and moving toward a more value-based care delivery,” says Melissa Jackson, senior associate director of policy at the American Hospital Association. “The risk-reward balance, however, is sometimes off kilter. … Savings are limited, and participation requires a high investment up front.

“Hospitals are doing it because it is the right thing to do, but there is a cost.”

There has been scant evidence that accountable care organizations can significantly reduce health care costs. Anderson points out that hospitals may not want to partake because the more they save, the less they ultimately make. “If I’m a hospital, why would I cut anything, because I’d rather have all of it? Most of them don’t, and that’s why it’s not working well,” he says.

Patel called accountable care organizations “training wheels” that would move the country into value-based care. They won’t make significant change, she says, but will start to change the conversation around health care payments and the approach to population health.

Dr. Ezekiel Emanuel, chairman of the department of medical ethics and health policy at the University of Pennsylvania, and Topher Spiro, vice president for health policy at the Center for American Progress, wrote a recent op-ed in The Wall Street Journal criticizing the emphasis the government is placing on the payment models.

“If Mr. Obama doesn’t act soon to control costs, escalating costs may ultimately threaten the sustainability of his coverage expansion – and his entire health-reform legacy,” they wrote.

Instead, they suggested bundling payments, which involves one fee for a range of services that are then distributed by a hospital. According to the Congressional Budget Office, this move could save the country about $50 billion over a decade.

But not everyone is optimistic that these various experiments can bring about significant savings. These alternative payment models are far from the norm. “There is a lot of confidence, and most of it is not warranted,” Anderson says. “There is nobody with significant power [in the health care industry] who wants to control health care costs. Until we have that, we will muddle along in terms of coming up with good ideas, implementing them and getting lukewarm results.”

Still, it’s difficult to say how much the country will suffer as a result of health care spending. Government officials warn decade after decade, year after year, that the country cannot sustain anymore spending on medical services. “We keep addressing the goal line of what’s acceptable as we reach it and pass it,” Anderson says. “It is cannibalizing other budgets, causing us to spend less on programs like education and housing.”

The government, he says, may hold the to control spending power, but is highly influenced by the health care industry.

Hayes agrees that the government can lead the effort. “Right now [hospitals] have one foot in fee-for-service and one foot in alternative payments, but Congress needs to send the message that we are going in this direction,” Hayes says.

This likely will require passing additional legislation.

“The Affordable Care Act was really about coverage,” Anderson says. “It wasn’t about affordable care.”

If you suffer from a serious chronic illness, or you need major but elective surgery: Are you better served by the familiar hospital right down the road or the prominent medical center 90 miles away? See what experts in lung disease, heart conditions, cancer and orthopedics say about when your local hospital is a perfectly good option for routine procedures and when to seek the next level of care from an academic medical center, a major hospital system or a specialty center.

Total hip replacements and knee replacements are among the most commonly performed surgeries in the U.S. and can very well be done in a community hospital versus a world-renowned orthopedics facility, says Dr. Alexandra Page, an orthopedic surgeon in a private practice in San Diego. Access is a big part of the equation, Page says – a highly acclaimed hospital center is no help to a patient if it’s unattainable due to distance or insurance coverage issues.

When considering high-tech treatments only available at certain centers instead of standard therapy, Page says, you should avoid being the first patient to undergo a procedure – but never be the last one to have it, either. Be ready to move on when a practice is outdated, she advises. However, she adds, “Some of the other things that sound sexy and appealing, trying to generate buzz, often don’t make a difference.” With robotic joint replacement, for instance, she says the research literature is “borderline at best.”

But there are times when specialty centers make sense. With musculoskeletal tumors, like breast cancer that’s spread to the bones, it’s important a specialist handles it, Page says. Similarly, community hospitals may not have the resources for complicated joint surgeries such as complex revisions for deep infections or worn-out implants. Orthopedic surgeons know when to refer patients onward, if their facility doesn’t perform a procedure often enough or specialized equipment isn’t available.

“In commonly occurring diseases, and commonly occurring problems, we’ve got pretty good data to show that a community hospital and community doctor can do a very good job handling those things,” says Dr. Otis Brawley​, chief medical officer for the American Cancer Society. “And indeed, sometimes, can do a better job than a tertiary​care facility.”

For example, Brawley says, a woman with early-stage breast cancer receiving standard chemotherapies Adriamycin and Cytoxan might do better locally. “If you go to a large university hospital or cancer center that employs 80 chemotherapy nurses – they give it, but they may not give it as often,” Brawley says. Instead, those nurses are giving a wide variety of chemotherapies to many more patients.

Clinical studies are a sign that a hospital is keeping up with the latest cancer research. “Many of your local hospitals actually participate in National Cancer Institute clinical trials,” Brawley says. Community hospitals offer convenience – patients often get through X-rays and other tests faster and spend less time waiting to see physicians, says Brawley, who practices at the Emory Winship Cancer Institute, a major referral center in Atlanta.

Higher-tier hospitals become more important as care becomes more complex, Brawley says. With lung cancer requiring chest surgery​, for instance, consider a referral facility. Also, “Tertiary care centers tend to be much better in taking care of the out-of-the ordinary, unusual cancers,” he says. With certain complex spinal tumors, a major cancer center is indicated.

Brawley says proton beam radiation – an expensive therapy delivered at a handful of U.S. centers – is only backed by evidence as a better choice in cases of pediatric brain tumors, and ​for adults, with tumors in the sellar region of the brain, because it avoids damage to nearby neurological structures.

For patients with lung conditions like chronic obstructive pulmonary disease, it’s important to find a local pulmonologist as well as a primary care doctor, says Dr. Albert Rizzo​, senior medical advisor for the American Lung Association. These providers can determine whether the community hospital can meet COPD patients’ needs, and when to refer patients to specialty centers, says Rizzo, who is chief of pulmonary and critical care medicine at Christiana Care Health System, based in Wilmington, Delaware.

Community hospitals can have excellent medical teams, Rizzo emphasizes, with physicians encompassing wide-ranging backgrounds, including experience in academic centers and research. However, he says, there should be a discussion of what comes next when asthma or COPD patients have been through a stepwise ap
proach to medical treatment, but suffer from worsening or unstable disease with flare-ups.

With referrals to specialty centers, patients may seek another opinion to make sure their treatment is appropriate and their diagnosis is accurate, Rizzo says. An academic center could be the best bet for clinical trials offering access to new medications. Certain lung procedures – such as surgical or nonsurgical volume-reduction techniques for patients with COPD – would be done at a referral center rather than a community hospital.

When people move to a new area, they should take an advance look into local health care options, says Dr. Andrew Freeman​, who serves on the patient-centered care committee of the American College of Cardiology. If you have a chronic condition like heart failure, where would you go? What’s a good place for common heart procedures?

“The vast majority of stents and bypass surgeries are done on a more elective or at least semi-elective basis – it makes sense to do a little bit of research and homework,” Freeman says. That includes going out to meet the surgeon, asking for a reference or two and reading online.

For programs like cardiac rehabilitation, a suburban hospital may be as good as better-known heart centers. “The community hospital gets a bad rap, but in many situations, the community hospital has nicer overall physical facilities than the older academic hospital,” says Freeman, director of clinical cardiology at National Jewish Health in Denver. “I always tell people that community hospitals may have some of the most talented people, the best outcomes – even better sometimes than academic hospitals.”

On the other hand, Freeman says, “If you have a complex condition that’s not sort of standard, going to a specialized center, what we call either a tertiary or quaternary referral center – usually academic hospitals – makes sense.” Those centers may excel in very precise areas, he says. The Philadelphia area where he trained was packed with academic teaching centers: “Some were fantastic for a heart transplant, and some were fantastic for TAVR [transcatheter aortic valve replacement], and some were fantastic for bypass surgery.”

Procedures like heart transplant ­obviously fall into the specialty-center category. Even so, Freeman says, “An enormous amount of evidence suggests that people who are undergoing heart transplant or valve transplant or bypass surgery – when they’re near family and support and caregivers, they do better.”

“People identify a hospital with their community,” says Dr. John Combes​, senior vice president and chief medical officer for the American Hospital Association. “In some small cities and certainly more rural areas, it may be the only hospital within 25 miles or so. In major metropolitan areas, sometimes the academic medical center is your community hospital.” What’s most important, he says, is for patients to go where their best support systems – family and community – are available. So traveling for a major procedure might not be best.

For objective criteria on overall performance and specific procedures, Combes advises patients to check outcomes not only on Medicare’s Hospital Compare but also Physician Compare.​ It might be better to turn to a major medical center, teaching hospital or specialty center if you have a very rare or obscure diagnosis, he says. Or consider a center of excellence around your particular illness if you’re seeking breakthrough treatments and related technology. Another option is to search for magnet hospitals, recognized by the American Nurses Credentialing Center for nursing excellence and outstanding patient care.

All American youngsters know the rules: Don’t take candy from strangers, play nice in the sandbox and call 911 during an emergency.

But what if the emergency is related to mental health?

More than 4 million people visited the emergency room due to a mental health condition from 2009 to 2010, according to the latest data from the the Centers for Disease Control and Prevention. That same year, Americans made 63.3 million visits to doctors offices, hospitals and emergency rooms for what were eventually diagnosed as mental disorders, the CDC also found. “The reality is, a mental health crisis is a common occurrence,” says Paolo del Vecchio, who directs the Substance Abuse and Mental Health Services Administration’s Center for Mental Health Services.

Here’s what to know if one strikes you or someone you love:

1. Get to know a psychiatrist.

Mental health crises rarely arise out of nowhere. “Psychiatric illnesses, for the most part, evolve slowly, and so there’s going to be a lot of warning,”  says Dr. Daniel Lieberman, the ​clinical director of the Department of Psychiatry at George Washington University Hospital. Ninety percent of people who die by suicide,​ for instance, give some indication they’re considering it, he says. “There’s this really irrational myth that people who talk about suicide do not commit suicide, and that’s exactly the opposite of reality,” he says.

That means that, in many cases, there’s ample time to get in touch with a mental health professional before a mental illness – be it a psychotic disorder, bipolar disorder or depression – becomes an emergency. In addition to providing ongoing care that can help prevent a crisis, he or she can be your first point of contact should an emergency arise. “If somebody does have a relationship with an outpatient psychiatrist, that’s the first place to go,” Lieberman says.

Such a partnership is key after the crisis, too, since almost 1 in 10 people discharged from state psychiatric hospitals are readmitted within 30 days, according to SAMHSA.​ “Having that kind of ongoing care is critical,” del Vecchio says.

Before a crisis, people with mental illness and their family members can benefit from educating themselves about a condition. Dr. Jeffrey Borenstein​, president and CEO of the Brain & Behavior Research Foundation, recommends​ reviewing the American Psychiatric Association’s consumer guide to the latest Diagnostic and Statistical Manual or reading other research-based materials on your loved one’s condition. “Having a book is extremely useful because it really empowers the family and the person to understand the cutting edge information about these conditions,” he says. 

You can also be proactive by ​getting to know the lay of the mental health services land in your area, del Vecchio says. Your community may have mental health services outside of hospitals such as mobile crisis teams, respite programs, and triage and assessment facilities. One way to find out is through SAMHSA’s treatment locator, which identifies mental health and addiction treatment settings based on ZIP code.

3. Recognize an emergency.

What constitutes a mental health emergency? Any time a person is an immediate danger to others or themselves, experts say. “In many ways, issues related to suicide are similar to having chest pain: This is an emergency, and it should be taken seriously,” Borenstein says. In other words, if someone around you is threatening violence, call 911​ or take the person to the nearest emergency room yourself, he says.

Other situations that warrant quick care include people who show signs of psychosis that affect their functioning such as delusions, paranoia or fear, Borenstein says. People who are extremely agitated, wild, overly active and unable to calm down should also raise red flags – particularly if they don’t respond to verbal interventions like saying, “Hey, can we sit down and talk?” Lieberman adds.

Sudden behavior changes should be taken seriously, too. “If something evolves rapidly, it’s probably not psychiatric,” Lieberman says. It’s probably something really, really serious like poisoning, and they just need to be taken to the closest emergency room immediately.” If you have a choice, head to an academic medical center, since clinicians there tend to be up-to-date on the most effective procedures and treatments, he says.

4. Know where (else) to go.

​The emergency room is often not the best place to go in a psychiatric crisis since the waits can be long and the psychiatric care insufficient, del Vecchio says. What’s more, most hospitals won’t hospital
ize patients for mental health conditions unless they are suicidal or homicidal, Lieberman says. “Mental health professionals are using hospitals less and less as time goes on,” he explains, due to the high cost of care and low rate of reimbursement from insurance companies. That’s part of the reason why it’s often a better idea to call your mental health care provider (if you have one) or your primary care provider if you don’t. 

Not everyone has quick access to a hospital or psychiatric care, either. “There’s a crisis in mental health care across the country,” says Virginia Sen. Creigh Deeds, who has focused on mental health care reform since his son died by suicide in 2013. “As your skin darkens, as your income goes down, as the people around you are fewer and fewer, your access to care is tough, very tough.”

If mental health care seems out of reach, try a hotline such as SAMHSA’s suicide prevention line or disaster distress helpline, which can walk you through the safest steps, or use a resource like SAMHSA’s locator, which can help you find the closest service. 

Dealing with a mental health crisis is extremely stressful. In order to handle it as effectively as possible, the loved ones affected by a crisis need to take care of themselves, too, del Vechhio says. This might be by connecting with family members or friends who have gone through similar situations or reaching out to an organization like the National Alliance on Mental Illness, which has chapters in every state, he says.

“It’s important to know that these types of things are fairly common and that they’re not alone,” Borenstein adds. “Treatment is available for their loved one.”

Somewhere in America, at a pace of about once per second, a patient checks into a hospital. With more than 33 million hospitalizations a year and so many patients on whom to sharpen their skills, hospitals could be expected to meet the most demanding standards for quality and safety.

Yet too many hospitals fail even those whose medical needs are relatively straightforward – such as hip replacement, uncomplicated heart bypass surgery or removal of a cancerous section of colon. The hospital that makes treating patients like these its bread and butter is the very definition of a community hospital, and it should perform at a high standard.

Even fewer hospitals excel at caring for patients with especially challenging or complex diagnoses, for whom the stakes may be a matter of life or death. For those patients, venturing beyond a trusted community hospital to seek care at a truly exceptional medical center, even one farther from home, may be the wisest option.

To help readers narrow their search for hospitals that best match their needs, U.S. News ranks hospital performance in 16 areas of complex specialty care and rates hospitals in nine bellwether procedures and conditions such as heart bypass, hip and knee replacement, heart failure and lung cancer surgery.

The Best Hospitals Honor Roll takes both the specialty rankings and the procedure and condition ratings into account. Hospitals received points if they were nationally ranked in one of the 16 specialties – the more specialties and the higher their rank, the more points they got – and also if they were rated “high performing” in the nine procedures and conditions. The top 20 point-scorers made up the Honor Roll.

Please see this blog post for important information about these rankings.

For most illnesses, patients do not need to go to an Honor Roll hospital, which may require onerous travel and where they may face greater expense of being treated outside their insurance plan’s network. To help readers find high-quality medical centers closer to home, U.S. News created Best Regional Hospitals. Similar to the Honor Roll, these regional rankings provide an overall assessment of a hospital’s performance across multiple areas of care. To be recognized on this year’s list, a hospital must have been either nationally ranked in one of 12 key specialties or received ratings of high performing in three or more of the procedures and conditions.

If you’ve consulted past editions of Best Hospitals, you’re bound to notice some hospitals that have risen or fallen in the rankings. Don’t make too much of year-to-year movements. It takes multiple years of progressive change to know if a hospital is truly improving or worsening.

For patients and their physicians, these rankings and ratings should be seen as just a starting point. Individual diagnosis, insurance coverage and personal priorities are important factors in making a personal best choice. With the latest U.S. News hospital-quality data at their fingertips, they can make their choices with greater confidence.

You need heart surgery, and a university hospital in your state has a renowned cardiology center – but that hospital is out of network. Or you’re hospitalized for a chronic lung condition and you want a second opinion from a pulmonology center that handles challenging cases – but your insurer denies a transfer.

Should you take “No” for an answer and stay put, or pay out of pocket? Before you do, you have the right to appeal an insurance denial, and while there are no guarantees, experts suggest how to improve your odds of success.

Be Aware of Appeal Options

If a simple administrative error is the reason for a denial, like an incorrect medical billing code, you could clear up the problem with a single phone call to your health care provider or insurance company, according to the National Association of Insurance Commissioners. That’s the best-case scenario. With private insurance, two basic levels of appeal exist, the NAIC explains: an internal appeal administered by the insurance company, and a next-level appeal by an independent third party.

A Medicare appeal is a five-level process. “If you do level one of the appeal and they approve you, you’re good to go,” says Dr. Tanya Feke, author of “Medicare Essentials: A Physician Insider Explains the Fine Print.” If that doesn’t work, she says, you can move on to the next phase. The first two appeal levels involve health reviews of your chart. Next, your request would go to an appeals council, followed by a local court. Level five is most formidable – taking your appeal to a federal district court. “After five phases, that’s as far as you can go,” Feke says. At that point, she says, you’re liable to pay on your own.

Make ‘Medical Necessity’ Case

“The general rule is, if you are covered by a health plan that either restricts covered benefits to providers or only provides the maximum coverage if you stay in network, then you need to be mindful of that,” says Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “And recognize in most cases, if you stray out of network, you will be penalized.”

You can appeal in certain circumstances, Pollitz says. For instance, you might need surgery that can’t be scheduled with an in-network hospital in time. You could require an intricate operation, like complex vascular surgery that’s beyond your local facility’s capabilities. Or you might benefit from care in a specialized rehab unit. Basically, you have a medical necessity that your network can’t provide.

To get any of this treatment approved – first, you have to ask. “You have to say to your plan, ‘I want to go out of network and get covered as though I was in the network, and this is my reason why,'” Pollitz says. “And then you have to give them a chance to agree.” If they disagree, then you can appeal it.

When you get a denial notice from your insurer, you might be tempted to tear it to shreds. But don’t. It’s important to preserve a paper trail – plus, that letter provides need-to-know instructions for an appeal.

Keeping medical and insurance documentation in order is a must when you’re questioning a coverage denial. And keep detailed records of conversations with insurance company staff – make sure to include dates and phone numbers, and take names. Collect all your evidence to support medical necessity, including prescriptions, X-rays, lab reports, referrals and discharge summaries from hospital records. Your health plan’s website might even provide supporting material within its policy and treatment guidelines.

The insurance company could have its own appeal form, or you may have to write a letter. When submitting an appeal request, give concrete reasons why you’re asking for a certain service or provider. It’s important to make yourself clear, Feke says: “Being vague is just going to make the process much more difficult and slow.”

If a scientific study shows that a specialized treatment is more effective for your condition, “Work with your doctors to get that study to your insurance,” suggests Dr. Otis Brawley​, chief medical officer for the American Cancer Society. He says he’s never seen an insurance company refuse to pay when patients can demonstrate that a good clinical trial, published in a peer-reviewed journal, proves the therapy they want is better in their case.

Enlisting your doctor’s support can help in several ways. For instance, getting approval for lung disease care in a special facility is more likely if the insurance company acknowledges a certain treatment is not available locally, says Dr. Albert Rizzo,​ senior medical advisor for the American Lung Association.

“That may require a peer-to-peer discussion with your local pulmonologist and the medical director of the particular insurance company,” Rizzo says. As long as a requested treatment is not considered experimental, he says, in-network requirements could often be waived when a proven therapy is not otherwise available. The patient’s pulmonary specialist would put the medical records together, he says, and send them to the center of choice, along with a letter of introduction. 

If you have questions about the appeals process, you can contact your state insurance department. It might also be worth reaching out to your attorney general’s office, Pollitz says. “Sometimes your state AG will just help people navigate this process, because it can be a little intimidating,” she says. “Typically if you’re in a situation where you’re asking for this kind o
f consideration – you’re probably kind of sick.” Which, she points out, can make it difficult to find the time or wherewithal to advocate for yourself.

When you receive a coverage denial, the letter should include information on consumer assistance programs in your state. “CAPs are essentially a system of ombudsman systems for consumers, established under the Affordable Care Act,” Pollitz explains. But there’s a caveat – because these programs aren’t currently funded, they may not be operating under full power, she says.

You can call Medicare directly for more information on appeals at 800-MEDICARE (1-800-633-4227).