Diagnosing Health-care System Ills, Showing How To Achieve Universal Coverage

"As the nation's largest medical specialty organization, the American College of Physicians is uniquely qualified to inform the public debate and the presidential campaign about reforming the U.S. health care system," said ACP President David C. Dale, MD, FACP.

"A growing number of studies by health policy experts have exposed the limitations of the U.S. health care system.

"Our recommendations provide evidence-based solutions to our country's many health care problems -- including the appalling lack of access to affordable heath coverage, the impending crisis caused by the insufficient supply of primary care physicians, rising health care costs, and excessive administrative and regulatory costs."

In the paper, "Achieving a High Performance Health Care System with Universal Access: What the USA Can Learn from Other Countries," published on the website of the ACP journal, Annals of Internal Medicine, ACP notes that spending on health care in the United States is the highest in the world and has been rising at a faster pace than spending in the rest of the economy.

Yet an estimated 47 million Americans -- nearly 16 percent of the population -- lack health insurance protection. Even among those with health insurance coverage, wide variations exist in terms of cost, utilization, quality, and access to health care services.

Based upon the lessons learned from a review of health care systems in 12 industrialized countries, ACP makes eight recommendations to improve health care in the United States:

1. Provide universal health insurance coverage to ensure that all residents have equitable access to appropriate health care without unreasonable financial barriers. Health insurance coverage and benefits should be continuous and not dependent on place of residence or employment status.

ACP calls on policymakers to consider adopting one of the following two pathways to achieve universal coverage:

• a pluralistic system in which government entities as well as not-for-profit and private, for-profit organizations ensure universal access while allowing individuals the freedom to purchase private supplemental coverage. An advantage of a pluralistic system is that it builds on the current American approach to provision of health services. The disadvantages of this system are that it is likely to result in inequalities in coverage and higher administrative costs, both of which are features of our current system. To be successful, pluralistic financing models need to provide a legal guarantee that all individuals have access to coverage and sufficient government subsidies to pay for coverage for those who cannot otherwise afford it.
• a single-payer system in which one government entity is the sole third-party payer of health care costs. The advantages of single-payer systems are that they generally are more equitable, have lower administrative costs, have lower per capita health care expenditures, have higher levels of patient satisfaction, and have higher performance on measures of quality and access than systems using private health insurance. The disadvantages of this system include potential shortages of services subject to price controls and delays in obtaining elective procedures. The financial model for a single-payer system must be flexible and expandable, given the projected growth in the population of the elderly and expected advances in medical science and technology.

In the new paper, ACP offers a comprehensive analysis of the advantages and disadvantages of pluralistic systems (Australia, Belgium, Denmark, France, Germany, Netherlands, New Zealand, and Switzerland) and single-payer systems (Canada, Japan, Taiwan, and the United Kingdom).

"The American College of Physicians does not want to replicate what other countries do," said Joel S. Levine, MD, FACP, chair of ACP's Board of Regents. "We try to identify approaches that the evidence shows are more likely to be effective and that ultimately will result in a health care system that is fair, cost effective, and efficient."

ACP further calls on policymakers to:

2. create incentives to encourage patients to be prudent purchasers by having access to health information necessary for informed decision-making;

3. avert a collapse of primary care by developing a national workforce policy that ensures an adequate supply of physicians trained to manage care for the whole patient;

4. redirect federal health care policy toward supporting the patient-centered medical home, an innovative practice system designed to strengthen the physician-patient relationship by having a primary care physician coordinate a team of health care professionals as they address the full range of a patient's needs;

5. provide financial incentives for physicians for care coordination, disease prevention, and achievement of evidence-based performance standards;

6. reduce the costs of health care administration by creating a uniform billing system for all services;

7. support with federal funds an inter-operable health information technology infrastructure;

8. encourage public and private investment in medical research and assessments of the comparative effectiveness of different medical treatments;

"A recent survey by the Commonwealth Fund of adults in seven industrialized nations indicates that Americans share ACP's view that the U.S. health care system is inefficient and could be greatly improved by providing access for all Americans to a primary care physician for continuous, comprehensive, coordinated care."

The Commonwealth Fund survey found that that U.S. patients are more likely to report experiencing medical errors, go without care because of costs, and say that the health care system needs to be rebuilt completely. As medical care becomes more specialized and complex, adults in all seven countries said they place high value on having a relationship with a primary care or personal physician who is accessible and coordinates their care.

Patients with this model of care -- a patient-centered medical home, which ACP proposes -- reported significantly more positive experiences, including having more time with their doctors, more involvement in care decisions, and better coordination with specialists and hospitals. They were also much less likely to report medical errors, receiving conflicting information from different doctors or to encounter coordination problems, such as diagnostic tests or medical records not being available at the time of care and duplicate tests.

In an accompanying editorial, Harold C. Sox, MD, MACP, editor of Annals of Internal Medicine, notes that the paper "recommends that the country seriously consider a single payer system as one way to provider universal access to health care. Countries have achieved universal access with pluralistic systems, not unlike our own. Both can achieve the greater end that should be our highest priority: equal access to basic health care for every citizen."

Reference: "Achieving a High Performance Health Care System with Universal Access: What the USA Can Learn from Other Countries" and the editorial will be published on the Annals of Internal Medicine Web site on Dec. 4, 2007, and will appear in the print edition of the journal beginning on January 1, 2008.