Question

Should the U.S. undergo a transformation of its health care policies? Should it be in the form of quality drivers, disease-specific initiatives, restraining physicians’ autonomy in cost reduction, improved consumerism of health care, or some combination of approaches? Is there an alternative approach you believe should be tried?

Answer 1

The United States spends more than any other nation on health care—well over twice the per capita average among industrialized nations. Health expenditures have grown from $1.3 trillion in 2000 to $1.7 trillion in 2003, and the portion of gross domestic product consumed by the health sector over that period has increased from 13.3 percent to 15.3 percent. Yet it is increasingly clear that our money is not buying the best care.

The U.S. health care system excels in some areas. But on many measures of quality, it delivers poor-to-middling results. Among the system's most significant problems is the growing number of Americans lacking health insurance—up from 39.8 million to 45 million between 2000 and 2003, a 14 percent increase that fell hardest on working adults.

What Americans want—and what our high spending should buy—is the best health care in the world. It's an achievable goal. But to reach it will require that we transform the health system to achieve better care for all.

Ideas of change in system

1. Agree on shared values and goals
Today, we tolerate a system that compromises the health of our workforce, strains our economy, and deprives many Americans of a healthy and secure retirement. We need a national discussion about our shared values and goals. We have the talent and resources to achieve a high-performance health system, but first must identify what we want as a society and hope to achieve over time.

2. Organize care and information around the patient
Each patient needs a "medical home," a personal clinician or primary care practice that delivers routine care and manages chronic conditions. People with ready access to primary care use emergency rooms less and know where to turn when they are worried about a medical problem. Continuity of care with the same physician over time has been associated with better care, increased trust, and patient adherence to recommended treatment.

Ideally, a patient's medical home would maintain up-to-date information on all care received by the patient, including emergency room services, medications, lab tests, and preventive care. It would not serve as a "gatekeeper" to other services but would be responsible for coordinating care, ensuring preventive care, and helping patients navigate the system.

3. Expand the use of information technology (IT)
As Donald Berwick, M.D., president of the Institute for Healthcare Improvement, has said, "Information is care." Physician visits and specialized procedures are important, but so is information that lets patients be active partners in their care.

4.Enhance the quality and value of care
The quality and cost of health care vary widely from place to place within the U.S. For example, according to the Dartmouth Atlas of Health Care, the cost of reimbursed Medicare outpatient services (adjusted for age, sex, race, illness, and other regional factors) varied in 1996 from $795 to $237 per enrollee, depending on the hospital referral region, with an average of $444. Such variations suggest that by examining the distribution of health expenditures, identifying best practices and spreading those models, we could make improvements. Such disparities suggest that by examining the distribution of health expenditures, identifying best practices, and spreading those models, we could make improvements.

5.Reward performance
Paul Batalden, M.D., coined the phrase, "Every system is perfectly designed to get the results it gets." If we want fundamentally different results in health care, we need to be prepared to change the way providers are rewarded. There is widespread consensus that current methods of payment are "misaligned," not only failing to reward quality but actually creating perverse incentives to avoid sicker and more vulnerable patients. And the "disincentives" go further. The current system typically pays hospitals on a per-case, per-diem, or charge basis; individual physicians on a fee-for-service basis; and integrated health care delivery systems on a capitation basis. Under those terms, hospitals may be penalized if they reduce hospitalization rates or shorten hospital stays, and physicians may be penalized if they keep chronic conditions well controlled. Only integrated health care delivery systems are rewarded for efficiency gains, but they are not rewarded for achieving higher qualit

6.Simplify and standardize
Health care administrative costs are far higher in the U.S. than in other countries and are the most rapidly rising component of health expenditures. This is partly explained by the major role of private insurers, whose premiums cover advertising, sales commissions, reserves, and profits. Instability of coverage, and high costs associated with enrolling and disenrolling millions of people each year from private and public health plans, is another factor. The proliferation of insurance products, each with its own complex benefit design and payment methods, also inflicts high administrative costs on hospitals, physicians, and other providers.