The presidential campaign has sparked a rigorous and much-needed national debate over health system reform, with polls consistently pointing to healthcare as the publics top domestic concern. Ensuring that everyone in the U.S. has health insurance is essential to establish a truly high-performance health system, but it must be pursued simultaneously with comprehensive reforms to control costs and improve quality and access.
Universal coverage should not be held hostage until we have a more efficient healthcare delivery system. But we need to start now to initiate the reforms necessary to achieve both high performance and real value in healthcare.
There is ample evidence that the U.S. health system falls short of achieving what it is possible to achieve in health status, quality, cost and coverage. As highlighted by the Commonwealth Funds Commission on a High Performance Health Systems national score card released in 2006, the U.S. does not stack up terribly well against other countries in mortality amenable to medical care, ranking 15th out of 19 countries. That statistic is a powerful measure of the impact of the health system itself (rather than poverty and other factors) on conditions that we are able to treat with good care.
We also know from the commissions state score card that there is enormous variation among the states on a number of measures of healthcare quality. For example, if all states reached the levels achieved among the top-performing states, almost 9 million more older adults would receive recommended preventive care, and almost 4 million more diabetics would receive care to help prevent disease complications.
The problem is not a lack of spending on healthcare. The U.S. spends far more on healthcare than any other nation. Furthermore, costs have been rising particularly rapidly in the past seven years. Since 2000, insurance premiums have increased 91% and medical outlays have increased 65%, while wages have increased only 24%. The growing burden of paying for healthcare undermines families economic security, and makes it harder for employers to provide health insurance for their employees.
Were headed in the wrong direction in the U.S. with costs rising and the ranks of the uninsured growing, up 8 million just in the past seven years. Today, 47 million Americans are uninsured, and even working middle-class insured families are feeling the squeeze of rising out-of-pocket costs and premiums. To inform the presidential campaign discussion, to help forge consensus and to spur action, the commission recently published A High Performance Health System for the United States: An Ambitious Agenda for the Next President, setting out five key strategies for reform. The first strategyaffordable coverage for all Americansshould be at the top of the agenda. The commission understands and recommends that sufficient financing will need to be committed to attain that goal. We believe that the most pragmatic approach to achieving universal coverage is to have the financing be a shared responsibility of federal and state governments, employers and individuals.
Second, we need to control healthcare costs. One way to do so is fundamental change in the way we pay physicians and hospitals. Rather than unfettered fee-for-service payments, we need payment that increases shared provider accountability and rewards quality and efficiency. New payment models to achieve this might combine fee-for-service payments linked to rewards for results, care-management fees, specific global payments for acute and chronic care, and capitation.
Third, we need to reduce the fragmentation of care by linking physicians and hospitals into coherent organizations that are accountable for the care they provide to patients and families over time. This improved organization will result in more coordinated care, better chronic-disease management and care that is accessible to patients when needed.
Fourth, we call for attaining improved quality and efficiency through a variety of policies including supporting healthy lifestyles and fostering evidence-based medicine and public reporting. A key part of this strategy calls for the funding and leadership necessary to ensure, within five years, that all provider groups are using electronic medical records.
Finally, we call for greater accountability and leadership at the national level. The commission recommends exploration of the creation of a new organization, perhaps modeled on the Federal Reserve Board, to oversee public and private insurance programs, to set national healthcare goals and to recommend policies to reach them.
The next two years present a rare window of opportunity to achieve real health system change. The challengesexpanding access to care, improving quality and controlling costsare considerable. But initiatives in states such as my own state of Massachusetts show us that action is possible.
The commission has demonstrated that we have great room to improve our health system to achieve higher value for the money we spend on healthcare. Our hope, as a commission, is that we can be equally helpful in demonstrating that there are solutionsthe ambitious agenda is our first step in doing so. The commission believes that comprehensive reform is possible within the next presidents tenure, given leadership, resources and commitment.
As the campaign continues, the commission will continue to provide analyses and information on healthcare reform models to stimulate the national debate.
James Mongan, M.D. is president and chief executive officer of Partners HealthCare and chairman of the Commonwealth Fund Commission on a High Performance Health System.