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BMJ. Mar 10, 2001; 322(7286): 572.
PMCID: PMC1119779

US healthcare system too geared to acute medicine

The healthcare system in the United States rewards inefficiency, is slanted towards care for acute rather than chronic conditions, and fails to take full advantage of electronic technology. The result is that it consistently fails to provide safe, high quality medical care. It is disjointed and inefficient and urgently needs reorganisation and reform. These were the conclusions of a new report from the US Institute of Medicine, National Academy of Sciences.

The current healthcare system cannot do the job. Building on or modifying it will not work, said the institute's committee on quality of health care in its latest report, published last week.

The committee was formed in 1998 and was charged with drawing up a strategy that would lead to substantial improvement in the quality of health care over the next 10 years. The report presents general principles rather than a detailed blueprint for the building of a new system of health care.

It is the second of two reports from this committee. The first appeared in November 1999 and dealt with errors in medicine. That report stimulated wide public concern and resulted in legislative moves by Congress. The latest report represents another step in the lengthy, if somewhat haphazard, evaluation of the healthcare system that has been under way in the United States for several decades. Americans spend about $1.1 trillion (£733bn) on health care, and it is widely believed that they are not getting their money's worth.

The committee's chairman, William Richardson, who is the president of W K Kellogg Foundation, Battle Creek, Michigan, said at a press conference in Washington, DC: “Between the care we have and the care we could have lies not just a gap but a wide chasm. We're going to have to reinvent the system, and the committee is proposing nothing less than that. There is a need for national leadership to recognise the problems that exist in the processes of care and the environment within which care is carried out and for rapid and significant change.”

He added: “We propose that there be established by Congress and carried out by the Department of Health and Human Services a $1m innovation fund to be spent over the next three to five years with the aim of improving healthcare processes and information technology.”

Mr Richardson pointed out that there are plenty of examples of high quality care, and doctors and hospitals are capable of providing it, but the system frequently prevents them from being implemented. The report calls on the entire healthcare enterprise to make “significant improvements” in providing safe, effective, timely, efficient, and equitable care.

The present reimbursement system rewards the inefficient, said Dr Molly Joel Coye, president of the Health Technology Center, San Francisco, and a member of the committee. When hospitals and doctors improve quality of care for their patients they often lose money, Dr Coye said.

She cited one study on 13000 diabetic patients that identified changes in the management of patients that could have saved some $10m. But if they had been introduced the improvement in patients' health would have resulted in fewer visits by patients, which in turn would mean a decline in reimbursement payments.

Another example she gave was a study showing that reducing the use of antibiotics in patients undergoing surgery improved outcomes and reduced complications, but because the patients were healthier the payments the hospital received for the surgery were smaller. “The result was the hospital lost hundreds of thousands of dollars.” Under such circumstances, she added, “you can't expect to see major progress in the quality of health care.”

Discussing chronic disorders, Mr Richardson said the current system was geared to providing care for acute rather than chronic conditions, even though the need lay in chronic conditions. Some 70% of healthcare expenditures were on the management of chronic diseases. The report listed 25 conditions such as heart disease, diabetes, asthma, arthritis, and depression, and pointed out that by focusing attention on these it would be possible to make sizeable improvements in the quality of care.

The report called for greater attention to evidence based approaches. Patients should receive care based on the best scientific knowledge, the report said. Care should not vary illogically from place to place or from doctor to doctor—a situation that has been widely documented in the United States in recent years.

Crossing the Quality Chasm: A New Health System for the 21st Century is accessible at http://nationalacademies.org

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Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Group
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