Criteria and guidelines for reforming the U.S. health care system

A cautionary tale: the dysfunction of American health care

Attempts to reform the US health care system in the 1980s and 1990s were inspired by the system's inability to adequately provide access, ensure quality, and restrain costs. In the era of managed care, after the Clinton administration's failed legislative effort at reform, access, quality, and costs are still problems, and medical professionals are increasingly dissatisfied. To aid understanding of why the system is now so dysfunctional, I have drawn upon discussions with thoughtful physicians about their direct experience. They raised important concerns not usually considered by health care reformers. Their central concern was about the abandonment of medicine's core values. They felt that health care has become dominated by large, bureaucratic organizations which may not honor these core values. Patients and physicians are often caught in conflicts between competing interests and demands. Those who work in health care may be subject to perverse incentives that discourage ethical practice. Health care leaders may be ill-informed, incompetent, self-interested, or even dishonest. Examples of attacks on the scientific basis of medicine have become more frequent. These worrying trends are not confined to the US. Physicians elsewhere should be skeptical of approaches to health care reform derived from the American model. European doctors should ensure the new health care initiatives do not undermine their core values or the best interests of their patients.

Rationing and the role of the emergency department as society's safety net

Emergency medicine has an integral role in the establishment of universal access to health care for all persons living in the United States. Currently, emergency departments provide the only unfunded mandate available to millions of American residents who otherwise have no access to health care coverage. Any effort to establish universal care must accept health care rationing as a basic principle, and establish a minimum standard of benefits to which all human beings are entitled in this country. People and employers should be allowed to purchase additional care based on their willingness and ability to pay, but under no circumstances should anyone be denied a basic package of health care benefits. Emergency care must be part of those basic benefits. Emergency medicine charges should be structured so that they are not unduly onerous to society, and should reflect true expenses, including marginal costs for nonurgent care. Emergency physicians (EPs) and hospital administrations should recognize their critical role in serving society in roles that are not strictly medical, and allocate resources to benefit the general population in the greatest way. This role will be expanded to include preventive care, to provide for basic pharmacologic coverage as needed, and to provide necessary immunizations when traditional primary care has failed. We have a moral obligation to recognize that resources are limited and to allocate them so as to benefit the greatest number of patients in the greatest way. As members of the medical profession best equipped to assume such a task, it is incumbent upon EPs to act as advocates to the public to enable us to fulfill this mission.

Clinician judgments of functional outcomes: how bias and perceived accuracy affect rating

OBJECTIVE

To evaluate the accuracy of clinician judgments of patient function, the susceptibility of judges to bias, and the relation between a judge's degree of belief in his/her accuracy of classification to observed accuracy when using the FIM instrument.

PARTICIPANTS

Fifty rehabilitation professionals.

SETTING

3 urban medical centers.

DESIGN

Four randomized experiments among subjects to examine the effect of potentially biasing information on FIM ratings of patient vignettes. Participants answered 60 true/false questions regarding patient function and FIM score and indicated confidence in the accuracy of their answers.

INTERVENTIONS

Manipulation of patient information.

MAIN OUTCOME MEASURES

The standard FIM 7-point scale, observed proportion of correct responses to the 60 true/false questions, and a 6-category confidence scale for each of the 60 questions were used as dependent measures.

RESULTS

FIM ratings assigned to others biased participants' FIM ratings of patient vignettes. Functional ability was overestimated when ratings in other domains were high and underestimated when they were low. Participants were overconfident in their ability to answer FIM questions accurately across all professional disciplines.

CONCLUSION

Bias and poor judgment of level accuracy play a significant role in clinician ratings of patient functioning. Blind ratings and training in debiasing are potential solutions to the problem.

The U.S. healthcare system after NHI: financial ramifications for providers and personnel

Although much attention has been paid to the general structure and possible implementation of a U.S. national health-insurance program, there remains the brass-tacks question of how such a plan would specifically affect today's providers and payers. Here the author outlines some of NHI's financial and organizational implications for patients, facilities, and staff.

Health services management manpower and educational needs with American health reform

This paper argues that our previous health services management (HSM) manpower projections may be overly optimistic as the health networks, managed care, capitated payment, and eventually global budgetary targets become the dominant themes to implement cost restraints, universal access, and social equity. HSM programs should, therefore, focus more on their educational pursuits to produce leaders for clinical management teams, who are able to allocate scarce clinical resources. A sensible strategy for HSM programs is to develop closer ties with the schools of medicine, public health, nursing, or allied health. These cooperative efforts would be particularly beneficial in teaching 'clinical-fiscal performance methodologies' to familiarize students with such concepts as clinical benchmarking, managing quality, resource management, and continuous quality improvement (CQI).

Access to family planning services and health insurance among low-income women in Arizona

This paper uses 1984 and 1989 Arizona survey data to explore the importance of insurance coverage for access to family planning services. In Arizona, Medicaid was provided through the Arizona Health Care Cost Containment System, a managed care model. Family planning was not provided in 1984 but had been added by 1989. Low-income women were 2.3 times more likely to receive services in 1989 than in 1984. Women in the system were 60% more likely to have received services. To improve access, health reform proposals should explicitly include family planning in managed care benefits packages.

An American macromanaged health care system?

The implementation of President Clinton's proposed health reform plan that ensures universal access and relatively comprehensive health insurance benefits to over 250 million Americans would have a significant impact on their hospitals, physicians, and other health care providers. With this projected coverage, the 36.7 million Americans now uninsured would demand an additional volume of services. It is doubtful, because of this nation's trade and budget deficits, that any significant increases in expenditures for health will be made available from the public sector. Therefore, providers in the US will need to deliver significantly more care with a minimal increase in total reimbursement. These conclusions are further supported by the experiences of the Canadian and the German macromanaged health care systems that provide considerably more hospital and physician services per person per year than the US at a lesser cost per discharge and percentage of their respective nation's gross domestic product. America may be heading toward macromanaged global budget targets, but for political and other reasons President Clinton's health reform plan will be implemented with a multi-payer, managed competition approach.

Strategies for reducing excess morbidity and mortality in blacks with systemic lupus erythematosus

The epidemiology of systemic lupus erythematosus suggests that the excess morbidity and mortality in blacks with the disease is related to lower socioeconomic status. Poverty and factors associated with poverty are powerful predictors of poor outcome in a variety of chronic diseases, and lupus appears to be no exception. A body of studies in other illnesses suggests ways to neutralize, at least partially, the disadvantages of lower socioeconomic status, even though the root causes of poverty may be insurmountable. These include improving access to quality health care; targeting educational programs to promote recognition and understanding of the disease and the comorbid conditions that affect outcome; implementing programs to improve self-monitoring and adherence to medical regimens; developing opportunities to facilitate homemaking, childrearing, and working outside the home; and applying psychosocial interventions to enhance self-confidence and social support. Improved access to quality health care may actually lead to a decrease in health care costs.

Medicare: the Canadian experience

In the 1940s Canada and the United States had similar lack of structure and reimbursement for diagnostic, hospital, and physician services. In Canada over the next 40 years there evolved a complex system mandated and partially funded by the federal government, but administered and delivered through 10 provincial and 2 territorial jurisdictions. Each must negotiate with federal government on cost sharing and deal with hospital budgets and physician compensation at the provincial or territorial level. The Medical Care Act of 1966 enshrined in law the five principles of public administration, universality, comprehensiveness, portability, and accessibility, converting all medical services in Canada from a privilege to a right. Any patient participation in hospital or physician charges came under increasing political attack. In 1984 the Canada Health Act specified financial penalties in federal transfer payments to provinces that permitted any direct patient charges. While Canada has "contained" health expenditures at 8.7% of gross national product, universal access to quality care is increasingly subject to rationing. The relationship between the profession and governments hard pressed to fund escalating costs in a deteriorating economy has been one of increasingly bitter confrontations. There have been four acrimonious doctors' strikes. More optimistically, there is now an emerging recognition of society's need to have physicians actively participating with other providers and governments to create a balance between access to quality health services and both public and private funding.