Tuesday, January 21, 2020

ACP has proposed a bold new plan to fix American health care. It’s about time someone did.

The American health care system is broken.
Patients know it. Physicians know it. People who study health care know it. You know it. I know it. 

Yet instead of doing something about it, we are told to accept the unacceptable because changing it will be too hard and the politics too difficult.

But isn’t time for someone with influence to speak out and say enough is enough, we can and must do better?

Yes, and that someone is the American College of Physicians. Today, ACP issued a bold call to action challenging the U.S. to implement systematic reform of the health care system in a series of policy papers published as a supplement in Annals of Internal Medicine.

“Better is Possible: The American College of Physicians Vision for the U.S. Health Care System” is a comprehensive, interconnected set of policies to guide the way to a better U.S. health care system for all. It includes a call to action, of which I am the corresponding author, which presents ACP’s vision of a better health care system for all, summarizes ACP’s key recommendation to achieve it, and challenges the U.S. not to settle for the status quo. The additional set of ACP policy papers in the supplement address issues related to coverage and cost of care, health care payment and delivery systems, and barriers to care and social determinants of health, and offer specific recommendations supported by evidence about ways the U.S. can change the status quo and achieve a better healthcare system for all. The papers are:

 “Envisioning a Better Health Care System for All: The American College of Physicians’ Call to Action

“Envisioning a Better Health Care System for All: Coverage and Cost of Care

 “Envisioning a Better Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health”

 “Envisioning a Better Health Care System for All: Health Care Delivery and Payment System Reform

One of the 10 vision statements in the Call to Action states that “ACP envisions a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford.” To achieve this, ACP recommends that the U.S. adopt either a single payer system or a public choice plan. 

Under single payer, everyone would be enrolled in the same publicly-financed and administered plan, with little or no role for private insurance. In a public choice model, everyone would have the option of enrolling in a publicly-financed program or keeping private insurance that would be required to have comparable benefits as the public option. 

This is the first time that ACP has expressly recommended either a single payer plan, or a public choice plan that would be made available to everyone. To our knowledge, we are the first national medical specialty society to do so; we are also the largest, representing 159,000 internal specialist physician and medical student members.

We offered both approaches as ones we can recommend because our examination of other countries with universal coverage found that there are some that have a single payer system, while others have systems where there is a mix of public and private coverage strongly regulated by the government and where coverage is guaranteed. In other words, there is more than one way to achieve universal coverage.

Single payer has the advantage of much lower administrative costs and associated administrative requirements on clinicians but is more disruptive because it would largely eliminate private insurance, while a public choice models is less disruptive and would achieve administrative savings compared to our current system, as more people choose the public choice option, but less than from single payer.

Also new and notable is that ACP recommends eliminating cost-sharing that creates barriers to high value care; including for patients with certain chronic conditions. We also proposed ways to control costs, including expanding global budgets and all payer rate setting, prioritizing spending, increasing investment in primary care, and considering comparative effectiveness in cost.

ACP didn’t just focus on coverage and cost. We propose major reforms in payment and delivery systems to center them on patients’ needs, including redesigning value-based payment programs that largely have not been effective in improving outcomes or lowering costs. Specifically, we call for

Eliminating “check the box” performance measurement reporting that take physicians’ time away from patients without resulting in better care,

Realigning incentives to support physician-led clinical care teams,

Eliminating disparities in payment between physicians’ cognitive services and procedures,

Redesigning Electronic Health Records to help physicians deliver patient-centered care.

Finally, we advocate for policies to reduce barriers to care based on where people live (social determinants), eliminate discrimination against and disparities in care based on personal characteristics, and devote more resources to the public health crises of firearms-related injuries and deaths, maternal mortality, tobacco and nicotine use, substance use disorders, and climate change.

ACP understands that our recommendations are provocative and controversial. We know that some of them will be fiercely opposed by those who financially benefit from our broken system. We know that politics will be hard. And, while we are confident that most ACP members support us in offering a bold vision for change, we also know that not every one of them will agree with everything we propose, and their concerns need to be respectfully addressed.

But the alternative is accepting the unacceptable: a broken U.S. health care system that, as we wrote in the Call to Action, “costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients’ interests; undervalues primary care and public health; spends too much on administration at the expense of patient care; fails to invest and support public health approaches to reduce preventable injuries, deaths, diseases and suffering; and fosters barriers to care and discrimination against vulnerable individuals.’

I am so proud that ACP is offering a vision for better health care system for all and of my contributions to making this happen.

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