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Reform Is No 'Either-Or': We Must Fix the Payment System Along with Access

Commentary on The Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey on the Presidential Candidates Health Reform Proposals by Darrell Kirch, M.D., president and chief executive officer of the Association of American Medical Colleges

In this year's election-charged political climate, the need to provide health care coverage for all Americans is the central focus of the reform debate. While universal coverage is certainly an essential goal, there are multiple other reforms on which we must focus if we are to attain the objective of a better U.S. health care system.

When it comes to addressing our nation's health care problems, there are no unsolved mysteries. The key success factors have been identified. They fall into two general categories: reforms in financing that will make health care coverage more affordable and accessible, and reforms in clinical care that will improve quality and effectiveness.

Those who seek the solution via changes in financing want to establish some form of universal coverage, better align payment incentives with wellness and prevention efforts instead of interventional care, and find effective ways to cut wasteful spending. Proponents of better clinical care advocate a "medical home" for every patient with coordinated disease-management for the chronically ill, increased participation in healthy behaviors, the need for ready access to data via electronic medical records and better end-of-life care.

As I listen to the current national dialogue about how to fix our health care system, I am reminded of advice I heard from Jim Collins, author of Good to Great: Why Some Companies Make the Leap … and Others Don't. Observing that many decisions are caught in the tyranny of the "either-or," Collins suggests finding the beauty in the "and." If we apply that lesson to our health care system, reforms both in the financing model and in the actual delivery of patient care are necessary to realize transformational change. The simple truth is that achieving only one or the other will not be sufficient to ensure that all Americans receive high-quality, safe, effective and affordable care.

The cornerstone of a balanced approach is that we need to provide both universal coverage and a "medical home" for each individual.

With the number of uninsured individuals at 47 million and climbing, the safety net is stretched to the breaking point. In 2004 alone, the cost of caring for the financially disadvantaged and uninsured by major teaching hospitals was $5.9 billion. We must ensure that everyone can obtain medical care outside the emergency room of a hospital.

At the same time, even many Americans who have health insurance feel "medically homeless" and lost in a system that, despite their insurance coverage, is difficult to navigate when they require care. As more individuals obtain health insurance, they also must have access to a trusted medical professional (or ideally a health care team) with which they have an ongoing relationship.

Hand-in-hand with extending coverage to all Americans is the need to implement better care models for the chronic illnesses that affect an estimated 100 million Americans, accounting for more than 75 percent of U.S. health care spending. Because the number of individuals with a chronic health condition is expected to rise 25 percent by 2020, better care-management strategies are critical.

Even before chronic illness occurs, we need to align provider and patient incentives with wellness and prevention efforts, and conduct more research on health-related behaviors. Inherent within this new paradigm is the need to promote wellness, stop the use of unnecessary tests and procedures, effectively adopt information technology, and minimize the excessive administrative costs intrinsic to the current delivery system.

The same attention is required for end-of-life care. By 2030, the number of elderly Americans will double as the baby boomers age. With this shift, the leading causes of death among people 65 and older—heart failure, cancer and stroke—will increase. Maintaining appropriate continuous care for these individuals as they move through the latter stages of illness will become crucial. In particular, we must shift to a system that attains a balance between prolonging life and attending to the suffering experienced by individuals in their final days.

The key ingredients for effective reform have been known for some time. Why then are we not closer to realizing our objective of affordable, accessible health care for everyone?

The reason, in my view, is that we continue to be trapped in reiterating the shortcomings of our current system, carrying on debates about who will pay the bill, and pitting the federal government against the private sector. This ideological dispute over whether the market or the government is better equipped to solve our problems all too often deteriorates into a bitter blame game. The intensity of this no-win debate may be the single biggest barrier to our progress in fixing our health care system.

If we are to climb out of this trap and find the political high ground, we must bring equal energy to changing multiple aspects of both our financial and clinical-care model. Only through such an act of political will can we achieve a national consensus about how to improve our health care system.

And once we achieve that consensus, we must force ourselves to set realistic timetables for key changes. Essential to our success will be continually building the evidence base about what works well, while simultaneously educating both current and future health care professionals to work in an ever-changing system.

It is encouraging that health care is a front-and-center issue in this year's presidential race. We can hope that this dialogue is not just election-year partisan politics, and that the vision for a better health care system will be a holistic one that will reach beyond universal coverage to embrace truly transformational change. The nation's medical schools and teaching hospitals are deeply committed to that change and stand ready to provide the high-quality care that all Americans deserve.

The views presented in this commentary are those of the author and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.

Publication Details



D. Kirch, Reform Is No 'Either-Or': We Must Fix the Payment System Along with Access, Modern Healthcare and The Commonwealth Fund, January 2008.