American College of Physicians (*)
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This position paper concerns improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it with health care in other countries. The concluding section proposes lessons that the United States can learn from these countries and recommendations for achieving a high-performance health care system in the United States. The articles are based on a position paper developed by the American College of Physicians' Health and Public Policy Committee. This policy paper (not included in this article) also provides a detailed analysis of health care systems in 12 other industrialized countries.
Although we can learn much from other health systems, the College recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. This caution notwithstanding, we have identified several approaches that have worked well for countries like ours and could probably be adapted to the unique circumstances in the United States.
U.S. national health expenditure (NHE) as a share of gross domestic product (GDP) and private and public shares of NHE, selected years 1965–2015.
Total NHE is the total amount spent in the United States to purchase health care goods and services during the year. Detailed definitions of the various components of NHEs can be found at www.cms.hhs.gov/NationalHealthExpendData/downloads/dsm-05.pdf. The left axis (public and private spending's share of NHE) relates to the 2 line graphs. The right axis (NHE share of GDP) relates to the bars. Data for 2006, 2010, and 2015 are projections. Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group.
The nation's health dollar, calendar year 2005: where it went.
“Physician and Clinical Services” includes offices of physicians, outpatient care centers, and medical and diagnostic laboratories. “Other Spending” includes dentist services, other professional services, home health, durable medical products, over-the-counter medicines and sundries, public health, other personal health care, research, and structures and equipment. Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group.
Table 1. International Comparisons of Key Health Care Statistics*
Table 2. National Scorecard on U.S. Health System Performance*
The Scorecard results make a compelling case for change. Simply put, we fall far short of what is achievable on all major dimensions of health system performance. The overwhelming picture that emerges is one of missed opportunities—at every level of the system—to make American health care truly the best that money can buy (53).
Percentage of national health expenditures spent on health administration and insurance, 2003.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance: Complete Chartpack (62) (www.commonwealthfund.org). *Data from 2002. †Data from 1999. ‡Data from 2001. §Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance.
Percentage of health care costs paid out of pocket, 2004.
Data are from a previous year for 2 countries: For the Slovak Republic, data are from 2003; for Japan, data are from 2002. Recent data are available only for 26 of the 30 Organization for Economic Co-operation and Development (OECD) countries. Source: Congressional Research Service based on OECD Health Data 2006 (October 2006).
Commonwealth Fund overall rankings of 6 countries, according to key indicators of performance.
Source: Calculated by the Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, and the Commonwealth Fund Commission on a High Performance Health System National Scorecard (65) (www.commonwealthfund.org). *Data from 2003.
Lessons learned and resulting American College of Physicians policy recommendations.
Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.
A personal physician leads a team of individuals at the practice level who collectively take responsibility for treating and managing care for the whole patient, rather than limiting practice to a single disease condition, organ system, or procedure.
Care is coordinated and/or integrated across all elements of the health care system (for example, subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (for example, family, public, and private community-based services).
The practice consistently uses evidence-based medicine, clinical decision-support tools, health information exchange, and other means to guide decision making and to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Patients are involved in planning, decision making, and accountability for ongoing medical care.
Patients have enhanced access to care through such systems as open scheduling, expanded hours, and new options for communication between patients, their personal physician, and practice staff.
Practices go through a voluntary recognition process by an appropriate nongovernment entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.
Practices receive payments that appropriately recognize the added value provided to patients (91).
Change payment policies to provide physician case management fees for care coordination services (92).
Encourage the use of EMRs (93).
Encourage the use of and exchange of electronic health care information (94).
Provide incentives for coordinated, patient-centered care (advanced medical home) (95).
Use evidence-based performance measures to improve the quality of care and providing incentives, including financial incentives, to reward physicians who meet or exceed standards (96).
Pay physicians for computer-based consultations (97).
Pay physicians for telephone consultations (98).
Promote professionalism and the patient–physician relationship, including physician responsibility to be prudent managers of resources (99).
Performance measures—if done right—have potential to assess physician performance, improve the quality of patient care, enhance the coordination and management of care, and reward physicians who meet or exceed the benchmarks set by performance measures. However, if applied in a bureaucratic, arbitrary, or punitive manner, performance measurement can hinder quality and harm patient care, undermine the physician–patient relationship, and cause physician frustration and career dissatisfaction (96).
Demonstrating that they lead to patient care that is safer and more effective as the result of program implementation.
Provide incentives for all physicians to perform better, continually raising the bar on quality.
Establishing or linking to technical assistance efforts and learning collaboratives so that all providers are motivated and helped to improve their performance.
Physicians are spending more time on insurance paperwork and less time seeing patients.
Physicians believe that insurers question their professional judgment too often.
Physicians have been forced to hire additional personnel to keep up with the abundant paperwork that insurance hassles create.
All health insurance industry forms should be uniform, with one form per task rather than a different form for the same task from every insurer (for example, a single durable medical equipment approval form and a single referral form).
All health care plans and hospitals should use one standard physician credentialing and recredentialing form.
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American College of Physicians. Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Ann Intern Med. 2008;148:55-75. doi: 10.7326/0003-4819-148-1-200801010-00196
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Published: Ann Intern Med. 2008;148(1):55-75.
Healthcare Delivery and Policy.
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