President's Message
The Best Health System
in the World

1. What's Wrong: A Snapshot
2. Lessons from the Scorecard
3. What's Right: A Blueprint for Change

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(18 pages)

4. Reorganize Health Delivery to Emphasize Patient-Centered Primary Care
Case in Point: Denmark
The U.S. is strikingly different from other industrialized countries in one important respect: its relative underinvestment in primary care. The U.S. has a much lower proportion of primary care physicians, and much better financial rewards for specialty care. A review of the literature indicates that better access to primary care lowers total cost and improves outcomes.(11)
Reorganizing the U.S. primary care system by moving to a "patient-centered medical home" model of primary care that employs teams of physicians, advanced practice nurses, and other professionals, and an organized system of off-hours care could improve the accessibility, effectiveness, and efficiency of care. A Commonwealth Fund survey of public views of the health system finds strong support for such a reorganization of care.
In Denmark, which has the highest public satisfaction with health care of any country in Europe, primary care is much more accessible than in the U.S.(12) Using a blend of capitation and fee-for-service payment, Denmark ensures that everyone has a primary care physician or "medical home," and generalist physicians typically provide services quickly, often in same-day appointments. An organized off-hours service assures accessible care from physicians 24 hours a day, seven days a week.
An interconnected health information system ensures that the patient's medical home has a complete and up-to-date record of filled prescriptions, lab and imaging results, specialist consultation reports, and hospital discharge information. Patients can e-mail their physician, book appointments, get prescription refills, and review their medication list online. Most importantly, patients are reminded about preventive services. As a result, 94 percent of women now have up-to-date Pap tests, and cervical cancer mortality dropped by 60 percent between 1988 and 2001.(13)
Most countries ensure that patients face no financial barriers to preventive and primary care, while the U.S. has been increasingly moving toward high-deductible health plans. Insurance should be designed to remove, not increase the financial barriers to early preventive and primary care. Public programs and private insurers could also help improve care coordination by offering enrollees choices of patient-centered medical homes or advanced physician practices that take responsibility for ensuring patients receive accessible care, appropriate preventive care, and ongoing management of chronic conditions, while coordinating their care across different providers.
Payment reform to reward medical homes including a blended system that incorporates features of fee-for-service, monthly per-patient fees, and bonuses for excellence in clinical quality, patient-centered care, and efficiency could make primary care a more rewarding choice of practice.
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