President Obama’s comments today to the American Medical Association in Chicago represent the slow, but certain, turning off the health reform supertanker that is the US healthcare system. Despite evidence of the need for improved clinical working practices, use of guidelines, better use of evidence, powerful groups have resisted over the years opportunities for root and branch change. Speaking to the AMA, Obama identified a few key barriers he sees as crucial to change:
- eliminate the notion of pre-existing conditions
- find alternatives to fee-for-service reimbursement
- share best practice better.
Of course, there are many other moving parts within each of these, and others he mentioned (e.g. generic medicines, clinical IT, etc.). But these three offer opportunities for substantial realignment with the US. In turn, and briefly, by eliminating the insurance barrier of pre-existing conditions means adopting population-based health risk. That moves the US to social insurance models familiar to Europeans. The problem will be overcoming the problem of free-riders, which be-devil some US policy commentary, but free-riders in automobile insurance claims are not quite the same thing as someone who is poor and in ill-health getting access to healthcare. Alternatives to fee-for-service opens the door to outcomes-based payment systems, enables better bundling of care across clinical pathways and more closely aligning payment to what actually happens to patients. By integrating care, financial incentives move closer to actual clinical and hospital work patterns; similarly, with innovative thinking about how to structure reimbursement based on outcomes, payers can more effectively encourage reform with hospitals, to move them away from fragmented care. Sharing better practice should seem the natural thing to do, given that everyone in the end does benefit when good practices are shared. But sharing better practice can undermine competitive advantage in market-driven health economies; by shifting to alternative payment systems, sharing practice will make more sense, especially if payers act together. However, ever mindful of potential for collusion, payment systems and information sharing must enable consumer and payer choice, rather than close down options, in an anti-competitive spirit.
This president is compelling in his expression of the anxiety so many Americans feel about what is wrong with their healthcare system, and he is to be commended for taking this challenge into the heart of the medical community. In that respect, I am optimistic that some sort of change will come in the US. More importantly for other countries’ healthcare systems, we see a lesson in a way to conduct health reform. His big-tent approach is a lesson for other countries that feel health policy and reform comes from aligning the interests of narrow interests, of specialist commentators, academics and civil servants.
One lesson to take away is that health reform is something that must be conducted within the society, with all the key participants engaged. It is not just the culmination of a rational research study, using contracted experts, who more often than not breathe each others’ air. No longer, I think, can international observers be critical of US reform intentions. Indeed, for some countries who think they have a pretty good and publicly funded system, US reform may show them to be small, mean-spirited systems, narrow in focus and costly overall.