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US health care
Addressing the crisis in US health care: moving beyond denial
  1. Don E Detmer
  1. Dennis Gillings Professor of Health Management and Director, Cambridge University Health, Judge Institute of Management, University of Cambridge, UK; Professor Emeritus and Professor of Medical Education, University of Virgina; and Member of the IOM Committee on “Fostering rapid advances in health care: learning from system demonstrations”; d.detmer{at}jims.cam.ac.uk
  1. Correspondence to:
 Dr G Neale, Clinical Risk Unit, University College, London, UK;
 g.neale{at}ucl.ac.uk

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A new report published by the Institute of Medicine in November 2002 creates a “game plan” for delivering a new system of health care through a set of demonstration projects in states across the US. The goal is to see these “seeds” grow over the next decade into universally accessible, safe, evidence-based, patient centred care for the US complete with a national health information infrastructure with common operating standards, secure communications, decision support, and knowledge management.

The US healthcare system is in a crisis and it is finally acknowledging this reality. Like other nations around the world, US health care faces mounting problems including rising costs, challenges to access to services, and persistently wide variations in safety and quality. Following the failure of the first Clinton Administration in the early 1990s to reform the US healthcare system through a complex “top down” approach and the managed care belt tightening of the past decade, no basic reforms have occurred. Meanwhile the population has aged another decade, causing a much greater need for integrated care to manage chronic illness, in addition to large increases in personal body mass. Efficiency measures such as robust information networks have scarcely penetrated to the level of primary care. Despite these many shortcomings, the nation has been slow to acknowledge that the healthcare Emperor is naked except for some high technology epaulettes sewn onto a backless examining gown.

In the 1980s and early 1990s Secretary of Health and Human Services Thompson, then Governor of Wisconsin, concluded that the nation’s social welfare system was hopeless and too expensive, and he led the national reform through a creative statewide demonstration that then spread across the nation. In mid June 2002 he concluded the same about the current non-system of health care in the USA. He asked the Institute of Medicine for suggestions for statewide initiatives that would serve as sites to move the country forward to a far better healthcare system by 2010. Among other items he pointed to rising costs of litigation and malpractice insurance rates that were in some instances causing consultants to move to other states or retire from active practice. A “fast track” committee was created which worked through the summer and released its report in mid November.

The timing is right for action. Coming on the heels of the oft quoted Institute of Medicine reports “To Err is Human1 and “Crossing the Quality Chasm”,2 this new report “Fostering Rapid Advances in Health Care: Learning from System Demonstrations3 acknowledges the lacklustre performance of the current system in dealing with both safety and quality. This newest report builds on the conclusions of the first two reports by urging the creation of a healthcare system that is safe, patient centred, effective, efficient, timely, and equitable. It recognises that at present the US healthcare system meets only some of these aims some of the time, and that it can do much better. While “To Err is Human” highlighted a problem and “Crossing the Quality Chasm” created a vision for the future, this newest Institute of Medicine report creates a “game plan” for seeing the new system emerge through a set of major demonstration projects in states across the nation. Genuine working partnerships will be needed between the federal and state governments and between state and local stakeholders.

“health care is a local experience, even in systems that are centralised in their management”

Perhaps for the first time in years, Americans may coalesce around both a sound vision and a practical strategy for creating a proper care system for the future. Currently, one political party controls the White House, the Senate and the House of Representatives and—although it is easy to forget today—at the time of his election the President was totally focused on domestic affairs. On the other hand, serious healthcare reforms in the US present a very difficult political challenge and state budgets are not conducive to expensive new experiments. Yet, something must be done and many agree on this point.

The “Rapid Advances” committee urges the federal government to support bold major (statewide, large regions, multistate) projects in five critical areas essential to a new and greatly improved healthcare system. These include:

  • chronic care demonstrations in 10–12 communities;

  • primary care demonstrations in 40 practice settings;

  • information and communications technology in 8–10 states;

  • universal health insurance coverage in 3–5 states; and

  • malpractice liability projects in 4–5 states.

One-time major federal funding is requested for only one of the five, assuring a “paperless” healthcare system—for example, an information and communications technology (ICT) infrastructure to assure computer based communications and interactions among all key stakeholders, especially patients. The goal is to create computer based patient, personal, and community health records to assure secure communications, decision support, and knowledge management in regions, but using standards to make the systems interoperable and scalable at the national level. Once developed, the system is expected to assume ongoing maintenance costs. Among the options is to draw upon the excellent nationally deployed ICT system developed within the Veterans Administration over the past few years. The government run Veterans Administration care system for those who have served in the military is the largest healthcare system in the US and its ICT system has won a number of major national awards for quality improvement when in competition with the best of the private sector hospitals and clinics.

One area focuses on creating initiatives for the management of chronic illness and another set of projects would create model primary care community health centres. The US has a number of such centres across the nation, but the systems rarely have the funding to assure that their successes can and are replicated elsewhere. Robust IT systems are advocated for these centres and for the chronic illness management initiatives. Another area urges statewide approaches to guarantee timely universal access to basic care services. This initiative would also cost money, but it appears that some states such as Maine wish to take on this challenge. A computer based system to identify eligibility rapidly is urged.

The fifth initiative in the list focuses on the malpractice liability crisis. Two models are advocated. The first model recommended for trial is a “no fault” approach like that in Sweden. The second involves “early offers” of financial payment to patients and their families at the time of a significant adverse event or injury so that the lengthy, costly and typically unsatisfactory results of the current tort jury system may be avoided and caregivers can also apologise directly for the injury or error. Today the adversarial nature of the tort system greatly impedes such interactions and, even when a patient gets a settlement, lawyers get a significant amount of any award.

The report urges creation of ongoing private-public partnerships for states and regions. The goal is to create major new components for the future healthcare system for the nation so that over 10 years a new system of care will develop. The report shows great respect for the intelligence and goodwill which exist throughout the nation, and it believes that a mix of government and private sector input is needed to create a system that can evolve over time and also achieve and sustain the needed high levels of performance. Stated differently, a “Washington inside the Beltway” top down approach would almost certainly fail and yet, at the same time, national leadership is needed for stimulus packages, for changing regulations and barriers, and for setting ICT standards to assure a robust yet flexible national information infrastructure.

The media received the report with substantial positive fanfare. Reports available at the time of submitting this editorial suggest that President Bush will mention the initiatives in his State of the Union address in January 2003.

What lessons may be useful to other nations from this most recent report? The obvious answer is that it is too early to say. However, it is already clear that health care is a local experience, even in systems that are centralised in their management. While the US now accepts that it has a genuine healthcare crisis on its hands, it also believes that only regional approaches with national support can assure that the key stakeholders come together in constructive initiatives capable of evolving over time. Healthcare systems may require national visions of what the Emperor’s robes should consist, but the stitching and final alterations will ultimately require the skills of the best seamstresses and tailors dotted across the land.

A new report published by the Institute of Medicine in November 2002 creates a “game plan” for delivering a new system of health care through a set of demonstration projects in states across the US. The goal is to see these “seeds” grow over the next decade into universally accessible, safe, evidence-based, patient centred care for the US complete with a national health information infrastructure with common operating standards, secure communications, decision support, and knowledge management.

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