Question

Opening Case Quality Health Care in the U. S. In his inauguration address, U. S. President Barack Obama mentioned the poor state of the U. S. health care system as a fundamental issue facing the nation and his administration. The sobering truth of America's health care system is that it dramatically under-performs. In an August 2008 poll by the Commonwealth Fund, 8 of 10 adults agreed with the statement that the health care system "needs either fundamental change or complete rebuilding". This becomes even clearer when comparing the system with those of its international peers. In 2000, the World Health Organization ranked the performance of the U. S. health care system 37th in the world. In this and other international comparisons, despite spending more than twice per capita than other developed countries, the U. S. were beaten on virtually every metric of health care cost, quality and access. In other words, they spend more and get less.

Scoring the U. S. health care system on key benchmarks achieved in other countries is about as complex a process as the new scoring system for gymnastics. Yet, experts at the Commonwealth Fund give the U. S. a score of 65 out of a possible 100, when examining how it compares to other countries on 37 different metrics for a high performing health care system, including life expectancy, preventable deaths, and timely doctors' visits. For instance, the Institute of Medicine estimates medical errors in the U. S. cost $17 billion to $29 billion each year.

Over the past 40 years, U. S. health care spending has grown on average between 1.3 and 3.1 per cent faster than the overall economy; 16.3% of the gross domestic product is consumed by health care. What's frightening is the constant upward trend. The federal agency that directs Medicare and Medicaid projects U. S. health care spending to double by 2017. It is estimated to cost more than $4 trillion and accounts for 20% of the GDP.

Other industrialized countries with above average per capita national income like the U. S. and systems that cover all residents, spend about half what the U. S. spends per person. In 2004, per capita spending was just over $6,000. France, Germany and Canada each spent roughly $3,100 per person and the UK spent less at $2,560. Yet, in terms of quality and access, each of these countries outperforms the U. S.

1. What is a benchmark?

2. What are some health care metrics?

3. What strategies can be used to improve the system ?

Answer 1

1.

Health is a fundamental driver of our overall quality of life. In this entry we focus on healthcare – one of the most important inputs to produce health. There are many other factors affecting health.Publicly funded healthcare is a legacy of the Age of Enlightenment.

The first examples of legislation on health insurance date back to the late 19th century.Data from these early systems shows that healthcare expenditure only began rising several years after the expansion of insurance coverage, with the discovery of powerful new treatments.

The impact that scientific developments had on healthcare expenditure is epitomized in the U.S. experience: in recent decades, as treatment possibilities expanded rapidly, expenditure on healthcare increased (private and public, both per capita and as a share of gross domestic product); and this occurred without major changes in insurance coverage. This had two important consequences: (i) the U.S. currently spends more government money per person on healthcare than many countries that fund universal programs, and (ii) spending is so concentrated that the top spenders account for more than percentage of total healthcare expenditure.

2.

Global expenditure on healthcare as a share of world income has been increasing, steadily but slowly over the course of the last couple of decades. In the background, however, there has been substantial cross-country heterogeneity, both in levels and trends. Regionally, high-income countries spend – and have been spending – a much larger share of their income on healthcare than low-income countries (about twice as much). Moreover, in contrast to high-income countries, in low and middle-income countries the public share of healthcare funding is much lower – although it has been catching up – and the role of out-of-pocket expenditures is much higher .

Healthcare financing in developing countries in the 21st century has been largely shaped by the flow of resources channeled through development assistance. These flows – which saw a steep increase after the introduction of the Millennium Development Goals – getting the resources spent by high-income countries on healthcare. Although this may seem small in proportion to the national commitments of rich countries, for low-income countries at the receiving end of the transfers.

This implies that development assistance for health, if suitably targeted and managed, has the potential of drastically reducing inequality in health outcomes: the robust empirically observed relationship between health outcomes and healthcare spending is indicative of large returns to healthcare investments, particularly at low levels of baseline expenditure.

3.

Improvement in quality of care is of fundamental importance to every stakeholder in health care. Strategies to improve quality of care are needed not just at the clinician-patient interface, but also at the regional and national levels.In deciding where to focus attention, however, there are many issues. For example, as noted subsequently, there are multiple elements of quality. In addition, each stakeholder brings their own particular perspective to the critical elements of quality. Finally, for every element of quality, there are multiple possible strategies to enhance quality of care.

Quality is being characterized according to the acronym STEEEP: Safe, Timely, Effective, Efficient, Equitable, and Patient-centered. As noted, the stakeholders in healthcare are multiple, but at minimum include patients, healthcare professionals (and their professional associations), hospitals, health agencies, third-party payors/insurers, and government. When the stakeholders are further broken down into their multiple layers such as different countries and levels of government, the number of stakeholders becomes even larger. If consideration is given to all elements of quality and all stakeholders with their multiple different perspectives, the scope of initiatives to improve quality becomes overwhelming.

Three initiatives, and the focus of this review, have the potential, either through government or professional associations, to improve quality of care: (1) pay-for-performance, the use of financial incentives to reward better quality of care; (2) safety checklist, a communication tool that standardizes surgical processes to enhance safety; and (3) practice guidelines, specific statements based on scientific evidence that aid clinical decision-making