Perspective for System Change in the U.S.

By Bill White, JSI senior consultant

Healthcare reform is a quietly dominating presence in addressing the economic picture of the United States. It is well documented that the U.S. spends more capita for healthcare than any other country in the world. Yet, there are questions about the value which we are realizing for that expense when measures such as life expectancy and infant mortality are used to evaluate the healthcare system. The United States still retains its position in the world as an economic power that does not have any form of national health insurance available to its population. Given that we spend more and our results do not show a healthier nation, what is needed to reform the system? Some would argue that reform is not the answer; rather, the system requires dramatic change.

Characteristically, the existing system encourages more care—often more specialty care and not necessarily more effective or more efficient care—being available to patients. The current system undervalues primary care. As it exists the current system does not promote the training and education of primary care clinicians (family practice, general internal medicine, pediatrics, and advanced nurse practitioners) and the methods used to reimburse these clinicians fails to value the importance of quality primary care. Changing the system will mean education of the general population about the importance of primary care as the access point and patient advocate for the healthcare system.

From a pragmatic perspective for system change, there must be a commitment to assure that all persons have access to health insurance that provides a basic benefit package emphasizing primary care and preventive health services. Premiums including co-insurance requirements need to be affordable and adjusted relative to family income. Any insurance arrangements must include requirements that support efforts to restrain costs as well as measuring performance to maintain quality and monitor the value of the provided services. Results that monitor costs and quality must be transparent and reported to the public using a format that is easily understood. The focus of any "reformed" system must be to assure that as patients we understand what is meant by terms such as quality and cost effective health services.

The successful creation of a partnership between the patient and the primary care provider will allow us to reform the current system and move toward one that values an accountable and coordinated system that can deliver cost-effective quality healthcare services. Promoting a strong working relationship between the patient and the primary care provider will encourage improved management of chronic care conditions, shared decision making for important healthcare issues and an opportunity to promote healthy behaviors.

An effective patient/primary care partnership will offer incentives for patients and the primary care clinician. Patients should experience an improved lifestyle as a result of early identification of health problems, whether medical conditions or mental health needs. Early identification can improve the outcome of many conditions that may progress to greater morbidity. Incentives for the patient may include: limited increase in the cost of health insurance along with better outcomes; incentives for primary clinicians should be linked to performance that recognizes the role of the primary care clinicians in improving or maintaining the health status of the patient.

Reform can begin with affordable health insurance but systemic change will require a commitment to revitalizing primary care.

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