TAKING NECESSARY STEPS TO
POSITION US HEALTH CARE TO BE THE BEST

LARRY A . GREEN

We need to act now

One has to wonder how much longer the United States will tolerate its health care system. The World Health Report 2000, a publication of the World Health Organization, left little doubt about the relatively poor position of the United States compared with other countries. On the heels of this embarrassing evidence, the Institute of Medicine (IOM) of the National Academy of Sciences concluded in its 2001 report, Crossing the Quality Chasm, that the US health care system is hopelessly flawed. According to the IOM, tinkering will not solve the many problems, and a complete overhaul is needed.

The authors of these reports assume, as do most of us, that the purpose of any health care system is to enhance health. In the United States, it could be argued that the purpose of the US health care system is to serve as an economic engine. From this perspective, the United States excels. Expenditures for health care in the United States represent about one-seventh of the US economy, with total health care expenditures exceeding the entire economies of most nations. Whether measured as a percent of gross domestic product, per capita spending, or percent of all public expenditures, the United States is the world leader. Table 1 illustrates this by comparing the United States with its proximate neighbors and a few of its economic competitors.

It is estimated that the United States spent more than $1.3 trillion on health care in 2000, with hospitals and physicians receiving 32 percent and 22 percent of this money, respectively. Prescription drugs accounted for 9 percent, nursing homes 7 percent, and government-supported public health about 3 percent. If key measurements of health and system performance are better in the United States than in countries spending less, a compelling case could be made that the return on these investments is justified—and that the United States reaps the double benefit of economic stimulation and improved health.

Regrettably, this argument does not hold true. As shown in Table 2, efforts at a standardized assessment by the World Health Organization of total system performance reveal that the United States ranks a dismal 37th place overall. System performance assessment, from the viewpoint of disease-adjusted life expectancy, dropped the United States down the list of nations to 72nd place. With further adjustment of the data using an index designed to reward factors such as responsiveness and convenience, the United States ranked higher, but still only 15th—far short of a proportionate return on our investment in health care.

Even with allowances for the limited effect of health care on overall health and for inconsistencies in the data on which these rankings are based, it is difficult to hold fast to the belief that the United States has the best health care system in the world. Of course, on any given day for a specific individual, a strong case can be made that the response of the health care system in the United States was stellar, even the best possible. Perhaps it is this recurring experience for some individuals at various locations and times that creates a bubble of mistaken faith that permits us to go on spending greater and greater sums as a nation for mediocre system-wide performance.

According to the Institute of Medicine, it is time to puncture the American myth of being the best, so we can take corrective steps to make superior health care a reality. The IOM has called for the redesign of the health care system, contrasting the existing strategies with new approaches that could result in a high-octane, high-performance health care system of which the United States could be proud. In its recent report, the IOM proposed six national aims for health care: safety, effectiveness, patient-centered care, timeliness, efficiency, and equity. The report contrasts what we have now with what could be. Instead of care based on visits, care could be based on continuous healing relationships. Instead of professional autonomy driving variability of services, care could be customized according to the needs and values of patients. Instead of professionals controlling care, patients could have a greater say. Information could cease being a record, and flow freely among those who need it. Decisions could be based on evidence, rather than training and experience. Responsibility to “do no harm” could become a tenet of the entire health care system, rather than just a physician’s creed. Secrecy could be replaced with transparency; and the system could anticipate, rather than react to, the needs of people. Instead of seeking to reduce costs, waste could be continually decreased. And instead of professional roles trumping system performance, cooperation among clinicians could emerge as the priority. Such is the vision of the IOM of what could become the American reality.

Even if there were consensus on all these points, there would be disagreement about how to proceed. The appropriate roles of the government and private sectors, and balancing the aspirations of the existing components of the health care enterprise, would challenge strategists to find ways to proceed without provoking paralyzing retaliation by powerful, well-funded interest groups. One commonly held view is that meaningful revision of US health care must await a disaster, or at least a serious economic downturn. But perhaps there are a few necessary, if insufficient, steps that could be taken now, to get the process started. I humbly suggest two interlinking strategies that will probably be necessary, now or later, to achieve the high level of performance the United States deserves. They are, of course, not new ideas.

1) UNIVERSAL INCLUSION

This term can incite powerful emotions and automatic alarm bells because it has come to mean various things to different constituencies. I use the term to mean “bring everyone in” and make some sort of health care coverage automatic. This term is not synonymous with single payer or government-run medicine, nor does it mean covering everything anyone wants. It is a policy that assumes that American ingenuity is up to the challenge of providing sensible health care for all of us, at an affordable price tag, perhaps around the same $1.3 trillion per year we currently spend on health care. Once adopted, this automatic coverage probably would shift debate from whether an individual or family deserves coverage to what is covered and how. This approach requires taking care of everyone with the resources at hand, rather than permitting or even encouraging the provision of abundant, sometimes excessive, care for some by excluding others. It is a policy that leans toward the needs of people in preference to the needs of health care providers. It is a policy consistent with the basic altruism of the American people—and doing something because it is right.

Consideration of universal inclusion resurfaces periodically in the United States without being fulfilled. If adopted, this policy would align the United States with the rest of the industrialized world, and it would almost certainly be a key component of a reform effort to position the United States as a provider of first-rate health care. As threatening as this arena has been for our politicians and those content with or benefiting from the status quo, isn’t it time to agree that this is the goal we seek, and establish a deadline for full implementation? Having exhausted partial, intermittent, unpredictable health care coverage strategies that create shelves of regulations, a patchwork of special programs for uncovered individuals, interference with personal life decisions, distorted negotiations, and forced discontinuity of care, we have another alternative. It’s time to label automatic inclusion of everyone as “the right thing” and “just do it.”

Surely, the rest of the world must laugh when the United States suggests that universal inclusion is beyond the means of the richest country in the world. Congress and the President should proceed to resolve this national embarrassment and declare universal inclusion a national goal, and establish a deadline for implementation, perhaps by 2004. The usual approaches for hammering out a suitable compromise can be exercised. After all, it is extremely difficult to envisage a first-rate health care system that systematically excludes large segments of the population. This seems like a necessary step, no matter what the details of subsequent reforms.

2) A “MEDICAL HOME” FOR EVERYONE

For years, patients, physicians, and politicians alike have espoused the value of comprehensive, continuous, coordinated care, but fragmented health care has prevailed in the United States. These three “C’s” are attributes of what has been labeled “primary care.” As defined by the IOM, primary care is primary in the sense of first, foremost, and fundamental care that resolves most health problems definitively close to home, and integrates whatever health care is required for each patient. Primary care should not be confused with “gatekeeping,” but seen rather as a reliable source of the health care most people need most of the time, with appropriate interfaces with public health and the entire scope of subspecialty medicine. Indeed, countries with stronger primary care systems achieve superior results compared to the United States.

For many in the United States, subspecialty care has come to mean scientific care and the “important stuff,” while primary care means the easy stuff that doesn’t really matter. This is nonsense, of course. The requirements of accepting any health care problem, however ill-defined, determining its nature and importance, and matching the problem to the best possible response is a huge challenge, an intellectual enterprise dependent on all the sciences, plus other types of knowledge, e.g. knowing the person and their usual situation. The best health care depends on an appropriate balance of primary and subspecialty care, both undergirded by relevant science and technology.

The United States now has a strong system of subspecialty care and a relatively fragile primary care system. This imbalance contributes to fragmentation, poor coordination, and poor achievement of important objectives such as preventive care. As with universal inclusion, it is difficult to imagine any serious reform that does not include organizing care and specifically establishing a place where people know they can go with any problem, be seen by a medical professional, and expect the best care in a well-coordinated and respectful manner. This is the terrain of primary care and the place could be called a “medical home.”

The good news for the United States is that after decades of decline, a robust, well-trained primary care workforce has emerged during the 1990s, ready for full deployment as the critical workforce for the nation’s medical homes. Family medicine reversed the decline in general practitioners that began in the 1930s, and now there are more than 60,000 board-certified family physicians who account for more patient visits than any other specialty (202 million in 1998). Family physicians, with their three years of post-medical school training, similar in length to general internists and pediatricians, are the specialists most often identified by people who have an individual physician as a usual source of care. When joined by the general internists and general pediatricians, these primary care physicians conduct a large portion of health care as it occurs in communities across the country. The rapid growth of nurse practitioners and physicians’ assistants, many of whom work in primary care, has also contributed to the availability of a well-prepared primary care workforce. Now these practitioners need a place to hold forth in their essential role that helps them do their work, is appropriately capitalized, and incorporates relevant technologies, such as information systems, imaging, and genetics. This place should provide, in a satisfying way, the latest and best care for most of the problems most people have most of the time.

The notion of a medical home is supported by practical experience and evidence of the salutary effects of having a usual source of medical care. For example, those who have a usual source of care, compared to those who do not, are more likely to receive effective preventive services, fill prescriptions, be hospitalized when needed—and NOT go without necessary care. This effect is additional to that of health insurance coverage. It takes little imagination to envisage the value of everyone having a medical home of their choice where they are known by name and become part of a comprehensive system of services. Much of the haphazardness experienced so often now by individuals could be replaced with an organized, accountable system of care. Fortunately, there are examples of such systems already in place.

CAN WE DO IT?

In an ideal scenario, everyone would be included in America’s health care system, and each individual would designate his or her own medical home. This designation could be changed, but would not be required to change because the individual changes jobs, retires, or suffers from a chronic illness. No one need be left out.

This system would not mean everyone automatically gets anything they want, but does assure everyone of a place to start. Clinicians and health care systems would know for whom they are accountable and be expected to achieve performance goals relevant to this population. Measuring performance among competing options would become feasible, and repeated measurement would allow tracking of progress or lack thereof. Such measurement is consistent with the IOM’s recommendations and is the terrain of the newest and smallest of the public health service agencies, the Agency for Healthcare Research and Quality (AHRQ). The IOM recommended a central role for this agency in improving the quality of health care in the United States, and AHRQ has already demonstrated its ability to mobilize the nation’s researchers and health care providers in the pursuit of scientifically grounded health care for all. All that holds it back now is a budget that is not yet matched to its mission.

The United States does not have the best health care system in the world. It could. There is enough money, a well-trained professional workforce capable of both primary and subspecialty care, and vibrant and fruitful biomedical and health services research enterprises to underpin health care reform efforts. The successful application of all this capacity is thwarted by complex issues that include incomplete inclusion of the population in the health care system and fragmented care. Universal inclusion and a medical home for everyone are probably key enablers that would fuel progress in almost any situation that might emerge with future health care reform. A commitment to these two components of a health care system can be made now and phased in as further incremental steps become possible.

There is an immediate need for federal action to provide this basic, national framework for health care reform. When everyone is included and has a medical home, things can be better for all those who receive care in the US health care system. The chances of actually having the best health care system in the world will be enhanced. Why wait any longer?

Additional Resources:

Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in America, Institute of Medicine, 2001 (can be downloaded at www.nap.edu).
Donaldson, Molla S. et al. Primary Care: America’s Health in a New Era. Committee on the Future of Primary Care, Institute of Medicine, 1996 (also at www.nap.edu).
Starfield, Barbara. Primary Care: Concept, Evaluation, and Policy.New York: Oxford University Press, 1992.
World Health Report 2000. World Health Organization, 2000 (can be downloaded at www.who.int/whr/2000/en/report.htm).

Larry A. Green (CC ’00), a practicing family physician, is director of the Robert Graham Center: Policy Studies in Family Practice and Primary Care in Washington, DC. Much of his career has been focused on developing practice-based, primary care research networks.

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