American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP issues recommendations for heath care system reforms

From the January ACP Internist, copyright © 2008 by the American College of Physicians.

By David C. Dale, FACP

In its policy paper, “Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries,” ACP made eight major recommendations based on comprehensive analyses of eight pluralistic systems (Australia, Belgium, Denmark, France, Germany, Netherlands, New Zealand and Switzerland) and four single-payer systems (Canada, Japan, Taiwan and the United Kingdom).

The paper makes the following recommendations:

1. The U.S. system should provide universal health insurance coverage. The system should 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 adopt either a pluralistic or single-payer system.

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. Successful pluralistic financing models 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.

  • Advantages: builds on the current American approach to provision of health services and is probably easier to implement in the shortest timeframe.
  • Disadvantages: results in inequalities in coverage and higher administrative costs, both of which are features of our current system.

A single-payer system in which the government serves as the sole third-party payer of health care costs. The system may be implemented and managed by a public entity or a combination of public and private entities. 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.

  • Advantages: generally more equitable; lower administrative costs; lower per capita health care expenditures; higher levels of patient satisfaction; and higher performance on measures of quality and access than systems using private health insurance.
  • Disadvantages: potential shortages of services; delays in obtaining elective procedures; and the possibility of price controls.

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

3. The system should 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. The system should redirect federal health-care policy toward supporting the patient-centered medical home, an innovative practice system designed to strengthen the physician-patient relationship.

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

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

7. The system should support with federal funds an interoperable health information technology infrastructure.

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

The report makes it clear that ensuring that everyone has health insurance isn’t enough. High-performing health systems in other countries have explicit workforce and payment policies to provide access to continuous, comprehensive and coordinated medical care by primary care physicians, based on evidence that the availability of primary care is positively associated with better outcomes at lower costs.

High-performing health-care systems make a greater public investment in basic and health services research, including research on the effectiveness of different types of treatments. They provide patients with access to information to help them make informed choices. They invest in interoperable health information technologies to improve care and have uniform billing systems to simplify administrative transactions.

I hope that you will find ACP’s recommendations to be:

  • responsible because they are consistent with ACP’s long-standing mission of advocacy for responsible positions on individual health, and on public policy issues for the benefit of internal medicine physicians and our patients.
  • thoughtful because our recommendations are based on the highest standards of evidence.
  • provocative because our intention is to provoke a national discussion, during this critical election year, on how to make the U.S. the best performing health care system in the world.

Please read the full text of this paper at www.annals.org and share your comments at www.acponline.org.

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