All the changes described so far would be much easier to accomplish in a climate of cooperation, both between the public sector and private insurers and employers and among health care providers. The goal would be to work together to improve the performance of the health system and eliminate duplication or complexity, drawing on the strengths of each party. Real collaboration would enable us to preserve patient choice—among physicians, health plans, and benefit packages—and in fact make those choices far more meaningful with better information and some degree of standardization.
Possible areas for public-private collaboration include the establishment of common payment methods, performance rewards, and benefit packages. The public sector should probably take the lead in funding research on cost-effectiveness and improving quality and efficiency, creating a national institute on clinical excellence and efficiency, and establishing information technology standards. The private sector should probably take the lead in promoting professionalism in health care and incorporating quality improvement processes in organizational accreditation and certification of health care professionals.
The most controversial determinations would involve insurance, and specifically whether insurance should be offered by private insurance companies, public programs, or both. It is worth remembering that the United States has long relied on a mixed private-public health insurance system. Medicare offers a self-insured option, as well as the opportunity for private insurance plans to participate. In most states, Medicaid offers self-insured public coverage and widespread participation by private managed care plans. The Federal Employees Health Benefits Program includes private managed care plans, but its preferred provider organization plans are at financial risk for administrative but not medical expenses.
(53) Retaining public insurance options as well as private managed care plans would give people enrolled in public programs the opportunity for choice.
Another major issue would be whether to use the purchasing clout of public programs, or a public-private consortium of payers, to negotiate prices for pharmaceuticals and health care services. Other countries use the power of government to obtain lower prices—a difference that in large part explains the higher cost of health care in the United States.
(54) Recent Fund-supported work, for example, shows that a comprehensive prescription drug benefit could be financed from the savings that would result if Medicare were to negotiate pharmaceutical prices comparable to those paid in other major industrialized countries.
(55) The downside might be reduced investment in pharmaceutical research and development. This represents a major policy choice—but, at a minimum, differentials in prices across payers should be narrowed.
The Commonwealth Fund seeks to be a catalyst for transformational change by identifying promising practices in the United States and internationally and by contributing to solutions that could help us achieve such a vision. The Fund's role is to help establish a base of scientific evidence on what works, mobilize talented people to transform health care organizations, and collaborate with organizations that share its concerns. Our communications efforts, including a redesigned website at www.cmwf.org, enable us to spread the word, share knowledge and experience, and urge the agenda forward. At this critical juncture, we hope our work will contribute toward achieving a 2020 vision for American health care with better access, improved quality, and greater efficiency.
(56)
