Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of PhysiciansFREE
Publication: Annals of Internal Medicine
Volume 172, Number 2_Supplement
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What would a better health care system for all Americans be like?
This is the question that the American College of Physicians (ACP) has been asking of its members since July 2018, when the ACP Board of Regents asked ACP's Health and Public Policy Committee and Medical Practice and Quality Committee to “develop a new vision for the future of health care policy,” to examine ways to achieve universal coverage with improved access to care, reduce per capita health care costs and the rate of growth in spending, reform clinician compensation, and reduce the complexity of our health care system.
To develop this vision and recommend ways to realize it, ACP considered evidence on the effectiveness of health care in the United States and other countries; solicited input from U.S-based members and ACP's policy committees; adopted draft recommendations for review by ACP's regents, governors, committees, and council members; finalized recommendations in response to this feedback; and submitted the recommendations for approval by the ACP Board of Regents. On 2 November 2019, the Board of Regents approved this call to action and 3 companion papers on coverage and cost of care (1), health care delivery and payment system reforms (2), and reducing barriers to care and addressing social determinants of health (3).
Why Does the United States Need a Better Health Care System?
In developing its new vision for health care, ACP focused on 4 questions:
1. Why do so many Americans lack coverage for the care they need?
2. Why is U.S. health care so expensive and therefore unaffordable for many?
3. What barriers to health care, in addition to coverage and cost, do patients face?
4. How do delivery and physician payment systems affect costs, access, quality, and equity?
As detailed in the accompanying position papers, there is a clear case that the U.S. health care system requires systematic reform. Too many Americans lack health care coverage. Despite historic gains in coverage with the Affordable Care Act, the United States is the only high-income industrialized nation without universal health coverage (4). Affordability is among the most commonly cited reasons for remaining uninsured (5, 6). The United States spends far more per capita on health care than other wealthy countries do, with nearly 17% of the nation's gross domestic product in 2016 directed to health care (7). Drivers of higher spending include higher prices for health care services, devices, and medications in the United States than in other wealthy countries (8). In addition, administrative costs account for 25% of total U.S. hospital spending (9). Complex medical billing, documentation, and performance reporting requirements for value-based payment initiatives have made the U.S. health care system one of the most administratively burdensome in the world. This burden takes time away from direct patient care, generates billions of dollars of unnecessary administrative costs, and contributes to unprecedented levels of burnout among physicians and other clinicians.
Despite high health expenditure, U.S. spending and prices generally do not correlate with better health outcomes. The United States consistently ranks last or near-last in access, administrative efficiency, equity, and health care outcomes (10). Mortality rates are higher in the United States than in comparable countries for most leading causes of death, although the United States does better than its peer countries on deaths from cancer (11). Life expectancy has been decreasing in the United States since 2014 (12). Environmental health hazards, poor nutrition, tobacco use, substance use disorders, prescription drug misuse, suicide, injuries and deaths from firearms, and maternal mortality are reversing progress made over generations of increasing life expectancy. Contributing to suboptimal health outcomes are the many systematic barriers to care that Americans face, including discrimination because of personal characteristics, such as race, ethnicity, religion, language, sex and sexual orientation, gender and gender identity, and country of origin.
Underinvestment in primary care in the United States also contributes to suboptimal outcomes. Evidence shows that greater use of primary care is associated with decreased health expenditures, higher patient satisfaction, fewer hospitalizations and emergency department visits, and lower mortality. A Primary Care Collaborative review found that primary care investment is associated with a decrease in ambulatory-sensitive hospitalization and emergency department visits, yet the national average for primary care investment is approximately 5% to 10% of total health care spending, depending on how primary care is defined; it also varies substantially across states. The United States spends much less on primary care than other peer countries. Organisation for Economic Co-operation and Development countries spend an average of 14% on primary care (13). Despite the value that internal medicine specialists and other primary care physicians bring to the health system, the current U.S health care system undervalues primary care and cognitive services (14, 15).
Much of the high spending and uneven health outcomes in the United States have been attributed to a fee-for-service payment system (16). Policymakers have sought to move toward value-based payment, but there is little agreement on how best to measure value across health care settings and patients with diverse medical and socioeconomic conditions and preferences. The clinical accuracy, ability of clinicians to act on measures of their performance, and usefulness of quality criteria across programs and payers have come under scrutiny.
Finally, health information technology (IT) holds promise to facilitate improvements in care, reduce administrative burdens of practice, and help both physicians and patients communicate and navigate the complexities of the health care system. However, ample evidence shows that health IT is not reaching these goals, but rather adding administrative burden to clinical practice (17, 18).
In summary, U.S. health care costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients' interests; undervalues primary care and public health; spends too much on administration at the expense of patient care; fails to invest and support public health approaches to reduce preventable injuries, deaths, diseases, and suffering; and fosters barriers to care for and discrimination against vulnerable individuals.
The ACP's Vision of a Better Health Care System for All
The ACP believes the United States can, and must, do better and offers the following 10 vision statements for a better health care system for all.
1. The American College of Physicians envisions a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford.
2. The American College of Physicians envisions a health system that ameliorates social factors that contribute to poor and inequitable health (social determinants); overcomes barriers to care for vulnerable and underserved populations; and ensures that no person is discriminated against based on characteristics of personal identity, including but not limited to race, ethnicity, religion, gender or gender identity, sex or sexual orientation, or national origin.
3. The American College of Physicians envisions a health care system where payment and delivery systems put the interests of patients first, by supporting physicians and their care teams in delivering high-value and patient-centered care.
4. The American College of Physicians envisions a health care system where spending is redirected from unnecessary administrative costs to funding health care coverage and research, public health, and interventions to address social determinants of health.
5. The American College of Physicians envisions a health care system where clinicians and hospitals deliver high-value and evidence-based care within available resources, as determined through a process that prioritizes and allocates funding and resources with the engagement of the public and physicians.
6. The American College of Physicians envisions a health care system where primary care is supported with a greater investment of resources; where payment levels between complex cognitive care and procedural care are equitable; and where payment systems support the value that internal medicine specialists offer to patients in the diagnosis, treatment, and management of team-based care, from preventive health to complex illness.
7. The American College of Physicians envisions a health care system where financial incentives are aligned to achieve better patient outcomes, lower costs, and reduce inequities in health care.
8. The American College of Physicians envisions a health care system where patients and physicians are freed of inefficient administrative and billing tasks, documentation requirements are simplified, payments and charges are more transparent and predictable, and delivery systems are redesigned to make it easier for patients to navigate and receive needed care conveniently and effectively.
9. The American College of Physicians envisions a health care system where value-based payment programs incentivize collaboration among clinical care team–based members and use only appropriately attributed, evidence-based, and patient-centered measures.
10. The American College of Physicians envisions a health care system where health information technologies enhance the patient–physician relationship, facilitate communication across the care continuum, and support improvements in patient care.
The accompanying policy papers (1–3) offer specific recommendations, supporting rationales, and evidence on ways the United States can move to achieve ACP's vision.
In “Envisioning a Better Health Care System for All: Coverage and Cost of Care” (1), ACP recommends transitioning to a system of universal coverage through either a single payer system, or a public choice to be offered along with regulated private insurance. Although each approach has advantages and disadvantages, either can achieve ACP's vision of a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford. The evidence suggests that publicly financed and administered plans have the potential to reduce administrative spending and associated burdens on patients and clinicians compared with private insurers. Other approaches were considered by ACP, including market-based approaches, yet ACP found they would fall short of achieving our vision of affordable coverage and access to care for all. The ACP asserts that under a single payer or public option model, payments to physicians and other health professionals, hospitals, and others delivering health care services must be sufficient to ensure access and not perpetuate existing inequities, including the undervaluation of primary and cognitive care.
The ACP proposes that costs be controlled by lowering excessive prices, increasing adoption of global budgets and all-payer rate setting, prioritizing spending and resources, increasing investment in primary care, reducing administrative costs, promoting high-value care, and incorporating comparative effectiveness and cost into clinical guidelines and coverage decisions.
In “Envisioning a Better Health Care System for All: Health Care Delivery and Payment Systems” (2), ACP calls for increasing payments for primary and cognitive care services, redefining the role of performance measures to focus on value to patients, eliminating “check-the-box” reporting of measures, and aligning payment incentives with better outcomes and lower costs. The position paper calls for eliminating unnecessary or inefficient administrative requirements, and redesigning health information technology to better meet the needs of clinicians and patients. The ACP concludes there is no one-size-fits-all approach to reforming delivery and payment systems, and a variety of innovative payment and delivery models should be considered, evaluated, and expanded.
In “Envisioning a Better Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health” (3), ACP calls for ending discrimination and disparities in access and care based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. This position paper calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems.
These are just a partial summary of the recommendations in the 3 position papers; considered together, they offer a comprehensive and interconnected set of policies to guide the way to a better a health care system for all. We urge readers of this call to action to review the 3 papers for a complete understanding of ACP's recommendations and the evidence in support of them.
Where Do We Go From Here?
The ACP believes that our recommendations, if adopted, would address many shortcomings in U.S. health care, but acknowledges that the recommendations do not address every area of needed improvement. In some cases, more research is needed for effective policy development. Because both are needed, the recommendations aim to balance the imperative for transformational changes with improvements in the current system.
The ACP is committed to ensuring that the patient's voice is paramount in creating a health care system that better meets their needs. The ACP also believes that physicians are uniquely trusted and qualified to offer solutions to the problems in U.S. health care.
We hope that those who challenge ACP's recommendations will offer their own thoughtful alternative solutions rather than just opposing ours.
The ACP rejects the view that the status quo is acceptable, or that it is too politically difficult to achieve needed change. Dr. Atul Gawande wrote, “Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try” (19). By articulating a new vision for health care, ACP is showing a willingness to try to achieve a better U.S. health care system for all. We urge others to join us.
References
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Crowley R, Daniel H, Cooney TG, et al; Health and Public Policy Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: coverage and cost of care. Ann Intern Med. 2020;172:S7-S32. doi: 10.7326/M19-2415
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Altman D. It's not just the uninsured—it's also the cost of health care. Axios. 20 August 2018. Accessed at www.axios.com/not-just-uninsured-cost-of-health-care-cdcb4c02-0864-4e64-b745-efbe5b4b7efc.html on 31 October 2019.
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Himmelstein DU. A comparison of hospital administrative costs in eight nations: U.S. costs exceed all others by far [Internet]. Commonwealth Fund. 8 September 2014. Accessed at www.commonwealthfund.org/publications/journal-article/2014/sep/comparison-hospital-administrative-costs-eight-nations-us on 31 October 2019.
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Davis K, Stremikis K, Squires D, Schoen, C. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. Commonwealth Fund. 16 June 2014. Accessed at www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror-wall-2014-update-how-us-health-care-system on 31 October 2019.
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Annals of Internal Medicine
Volume 172 • Number 2_Supplement • 21 January 2020
Pages: S3 - S6
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Published online: 21 January 2020
Published in issue: 21 January 2020
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Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians. Ann Intern Med.2020;172:S3-S6. [Epub 21 January 2020]. doi:10.7326/M19-2411
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Where do we go from here: Research for development of Public Policy
I will be starting a MPH this summer, where I hope to learn more about how all of this works. For now, I would greatly appreciate hearing from anyone who is a little further down the road!
Not Enough
Where maybe 80% of all hospital admits in the US are avoidable, when the average diagnostic journey has at least 2 flaws, where the therapeutic journey is fraught with wrong therapy, to much therapy, to little AND occurs with little to no patient preference elicitation, no wonder the bill is so high and of dubious value. As someone said, "Every process is perfectly designed to get the results it gets." (Arthur Jones). Incrementalism may, and only may, achieve some of the noted goals 4 generations from now, at best. And, a focus on payment, coverage, etc. component of the effort is important but requires a complete overhaul. The delivery system, in general, is antiquated. Why are activities you want to happen, read prevention, mixed with rare or uncommon events. And, mixed with chronic care that has so many of its own care requirements. No wonder excellence is elusive.
And specifically to my ACP colleagues, figure out how to deliver excellent care 99+% of the time.
Why not bring the care to the customer versus the customer to the care, especially for care that one wants all to have that should have, no more, no less.
The money will follow the improved/transformed value proposition. The goals proposed will not seem as elusive as they do now.
Clean our own house, make it impeccable and settle for nothing less.
Medical Liability Cost.
I agree with much of the ACP recommendations. There has always been a tremendous disparity between payments for doing versus payment for the much more important cognitive function of primary care and IM. But having practiced for over 40 years (Internal Medicine and Gastroenterology), the ouitrageous medical liability costs in this country must to be addressed to reduce unnecessary costs associated with the need to CYA from our reckless injury attorneys. Some states have been more effective than others but Washington has never been willing to look at this problem (witness the "affordable care act").
Elimination of waste
1. I strongly believe that the establishment of a trusting relationship with a patient, taking a history that includes the usual PMH and asocial, employment/professional/educational/psychiatric/psychological/relevant travel/military experience and, depending on what is gleaned from above, additional history. This cannot be accomplished in 15 minutes. A questionairre to be filled out by the patient can be helpful but is only a starting point.
2. The intrusion of a "Pharmacy Benefits Manager" (PBM), wastes physician, staff, pharmacist and even insurance company time. The PBM may cause harm to the patient by delaying access to necessary medication and have been known to endanger patients by recommending different medication. Example: Substitute HCTZ for an ARB in an elderly paient with glucose intolerance, weell controlled HTN and strong FH of DM.
Disclosures:
I have a strong interest in staying alive and require appropriate access to my physician and medications.