Improving Health Through Health System Reform

In Reply. —The US health system is witnessing an alarming and rapid corporate transformation with profound implications for health care quality. Rather than addressing this disturbing reality, or engaging the 10 quality principles we outlined for US health system reform, Dr Noel echoes a series of inaccurate assertions about Canada, and instead offers the administratively unwieldy and inequitable remedy of individual retirement accounts. He misrepresents Canada as plagued by medical cost inflation, shortage, long queuing, and rationing. Recent Canadian data show that average real per capita health expenditures increased only 1.4% annually from 1987 through 1993, and have actually decreased for the latter 2 years. 1 While effectively containing costs, Canada provides more care— more physician visits, more hospital days, more procedures, and even more bone marrow transplantations (and at a more appropriate stage)—than the United States, while achieving the highest level of satisfaction in the world and winning

1% Steps for Health Care Reform: Implications for health care policy and for researchers.

Foundation Activities To Improve Health Around The World

Initiating Human Papillomavirus Vaccination at Age 9: Strategies for Success From 5 US Health Systems.

America's cancer care crisis

To the Editor. —Dr Lundberg's 1 wish list for US health system reform rests on belief in a nonexistent medical marketplace. The actual marketplace is a classic example of supply-side economics. Practicing physicians, one component of the actual marketplace, set their own fees in a way not to threaten those of their colleagues. There are practically no market pressures that would lower prices. When we physicians order tests, prescribe drugs, or schedule procedures, it is the rare patient who can effectively raise objections. The actual marketplace has placed physicians' incomes in the top 1% of incomes in the nation. Lundberg rates the single-payer health plan zero on the physician-liability question. The truth is that the single-payer plan would eliminate large awards for out-of-pocket health care expenses for iatrogenic disabilities, and this fact alone should lower liability insurance costs. But the major problem in the Editorial is the uncritical approach taken

To the Editor. —Dr Lundberg's 1 wish list for US health system reform rests on belief in a nonexistent medical marketplace. The actual marketplace is a classic example of supply-side economics. Practicing physicians, one component of the actual marketplace, set their own fees in a way not to threaten those of their colleagues. There are practically no market pressures that would lower prices. When we physicians order tests, prescribe drugs, or schedule procedures, it is the rare patient who can effectively raise objections. The actual marketplace has placed physicians' incomes in the top 1% of incomes in the nation. Lundberg rates the single-payer health plan zero on the physician-liability question. The truth is that the single-payer plan would eliminate large awards for out-of-pocket health care expenses for iatrogenic disabilities, and this fact alone should lower liability insurance costs. But the major problem in the Editorial is the uncritical approach taken

commentary describes the Veterans Health Administration (VHA), the largest public integrated health care system in the United States, from the point of view of someone who has worked as a health services researcher in VHA for more than a decade and now lives and works in Canada. It traces the historical evolution of the VHA and outlines the important contributions it has made that are relevant to current discussions about health insurance and health system reform. The VHA reflects a very different model of care, financing, and delivery than the models that dominate the US health care industry. In this, it is more like public health delivery systems in other countries, sharing features with the National Health System in England and provincial health care systems in Canada, and provides an interesting case study for consideration in discussion of health insurance and system reform.

As reforms in access to and provision of US health care accelerate, medical education faces an era of both fine adjustments and radical change. Changes proposed at national level, as well as those to be implemented at state and local levels, will impact to some degree every component of the existing medical education system. How the proposed elements of this newly engineered system have begun and will continue to alter the education of health professionals will be the focus ofthe journal's 1994 medical education issue. We would especially like to see research papers addressing the educational preparation of those currently delivering and preparing to deliver primary care medical services in the United States. How do medical schools, residency programs, national organizations, federal agencies, and states define the appropriate education for those providing primary care services and how do they determine their scope of practice and assess their competence?

Suicide is a major public health concern, and as most individuals have contact with health care practitioners before suicide, health systems are essential for suicide prevention. The Zero Suicide (ZS) model is the recommended approach for suicide prevention in health systems, but more evidence is needed to support its widespread adoption. To examine suicide attempt rates associated with implementation of the ZS model in outpatient mental health care within 6 US health systems. This quality improvement study with an interrupted time series design used data collected from January 2012 through December 2019, from patients aged 13 years or older who received mental health care at outpatient mental health specialty settings within 6 US health systems located in 5 states: California, Oregon, Washington, Colorado, and Michigan. Analyses were conducted from January through December 2024. The ZS model was implemented in 4 health systems at different points during the observation period (2012-2019) and compared with health systems that implemented the model before the observation period (postimplementation). Implementation included suicide risk screening, assessment, brief intervention (safety plan, means safety protocol), and behavioral health treatment. The primary outcome was a measure of standardized monthly suicide attempt rates captured using health system records and government mortality records. Suicide death rates were also measured as a secondary outcome. There was a median of 309 107 (range, 55 354-451 837) unique patients per month. In 2017, there were 317 939 eligible individuals (63.2% female). Baseline suicide attempt rates were at least 30 to 40 per 100 000 individuals at each implementation site and decreased to less than 30 per 100 000 individuals at 3 sites by 2019. Decreases in suicide attempt rates were observed at 3 intervention health systems after site-specific implementation: health systems A and B had decreases of 0.7 per 100 000 individuals per month and C, 0.1 per 100 000 individuals per month. System D evidenced a similar suicide attempt rate after implementation (before implementation: median rate: 35.0 [range, 11.0-50.3] per 100 000 patients per month; after implementation: median rate: 34.3 [range, 18.5-42.0] per 100 000 patients per month). The 2 postimplementation health systems maintained low or declining suicide attempt rates throughout the observation period. The rate at system Y decreased by 0.3 per 100 000 individuals per month across the observation period. The rate at system Z began at 11 per 100 000 individuals per month and declined by 0.03 per 100 000 individuals per month during the observation period. Two systems evidenced reductions in the suicide death rate after implementation: system B declined by 0.2 per 100 000 individuals per month and system C by 0.1 per 100 000 individuals per month. In this quality improvement study, ZS model implementation was associated with a reduction in suicide attempt rates among patients accessing outpatient mental health care at most study sites, which supports widespread efforts to implement the ZS model in these settings within US health systems.

BackgroundHow do health systems in the United States view the concept of merger and acquisition (M&A) in a post-COVID 19 “new normal”? How do new entrants to the market and incumbents influence horizontal and vertical integration of health systems? Traditionally, it has been argued that M&A activity is designed to reduce inequities in the market, shift toward value-based care, or enhance the number and quality of health care offerings in a given market. However, the recent history of M&A activity has yielded fewer noble results. As might be expected, the smaller the geographical region in which M&A activity is pursued, the higher the likelihood that monopolistic tendencies will result.ObjectiveWe focused on three types of competition perceptions, external environment uncertainty–related competition, technology disruption–driven competition, and customer service–driven competition, and two integration plans, vertical integration and horizontal integration. We examined (1) how health system characteristics help discern competition perceptions and integration decisions, and (2) how environment-, technology-, and service-driven competition aspects influence vertical and horizontal integration among US health systems in the post-COVID-19 new normal.MethodsWe used data for this study collected through a consultant from a robust group of health system chief executive officers (CEOs) across the United States from February to March 2021. Among the 625 CEOs, 135 (21.6%) responded to our survey. We considered competition and integration aspects from the literature and ratified them via expert consensus. We collected secondary data from the Agency for Healthcare Research and Quality (AHRQ) Compendium of the US Health Systems, leading to a matched data set for 124 health systems. We used inferential statistical comparisons to assess differences across health systems regarding competition and integration, and we used ordered logit estimations to relate competition and integration.ResultsHealth systems generally have a high level of the four types of competition perceptions, with the greatest concern being technology disruption–driven competition rather than environment uncertainty–related competition and customer service–driven competition. The first set of estimation results showed that size, teaching status, revenue, and uncompensated care burden are the main contingent factors influencing the three competition perceptions. The second set of estimation results revealed the relationships between different competition perceptions and integration plans. For vertical integration, environment uncertainty–related competition had a significant positive influence (P<.001), while the influence of technology disruption–driven competition was significant but negative (P<.001). The influence of customer service–driven competition on vertical integration was not evident. For horizontal integration, the results were similar for environment uncertainty–related competition and technology disruption–driven competition; however, the significance of technology disruption–driven competition was weak (P=.05). The influence of customer service–driven competition in the combined model was significant and negative (P<.001).ConclusionsCompetition-driven integration has subtle influences across health systems. Environment uncertainty–related competition is a significant factor, with underlying contingent factors such as revenue concerns and leadership as the leading causes of integration plans. However, technology disruption may hinder integrations. Undoubtedly, small- and low-revenue health systems facing a high level of competition are likely to merge to navigate the health care business successfully. This trend should be a focus of policy to avoid monopolistic markets.

European health systems face scrutiny in US debate

Last month I visited Boston in the United States, and in particular the Beth Israel Deaconess Hospital. On a sample of one, it struck me that healthcare for those served by the US health system and for those who work in it is vastly different to the UK experience. A sense of calm and dignity pervaded the hospital. Staff, and even patients, smiled as you passed them on corridors and in lifts. A harpist strummed soothing melodies, and ‘public safety officers’ lurked discreetly in case the harpist's notes failed to keep the peace. A visitor might easily fall in love with US healthcare. But then the US system struggles to match UK health outcomes on around double the per capita spend. The US health system is ranked 50th for life expectancy and scores low on some measures of responsiveness and quality of healthcare. Just under 50 million people are uninsured and find healthcare hard to access. This blot on US healthcare's landscape is its most visible. US healthcare, then, is a story of success and failure travelling hand in hand. The success stories are instructive for health systems everywhere, indeed the obsession of UK health leaders for over a decade has been to seek guidance from their US counterparts. But the failures are an equally potent warning, a lesson in how not to do it. This month's issue carries several pieces comparing the US and UK approaches to disparities in healthcare – and healthcare more broadly. Just as economic arguments are now driving our healthcare agenda and further restructuring, the US debate is driven by economics. Should the state really bear the cost of universal coverage? While the UK's decision and passion has been that it should, the US has traditionally taken the opposite view. President Obama has now lurched towards better healthcare for the uninsured, a seismic shift in the US health system, and a legacy policy that will dominate history lessons about his presidency. Now the US debate has become even more passionate with Republicans defending the American Way to the last sharp intake of breath. It is in this political firestorm that a Harvard professor has become the focus of furious debate. Don Berwick, paediatrician and head of the Institute of Healthcare Improvement, is Obama's nominated head of the Centers of Medicare and Medicaid Services, a role that will be influential in US health reform. It is hard to criticize Berwick as a doctor, leader or champion of quality improvement. Yet Berwick has become a target for Republicans opposed to Obama's reforms. And Berwick's sin is a simple one: he once declared his love, albeit reservedly, for the NHS. Naughty man, I hear he also enjoys tea.

GERMANY, and Canada, maybe England. These countries are where US policy makers look for lessons applicable to reform of the US health care system. Why not France? France provides almost universal coverage with a uniform comprehensive benefit plan that, unlike those in the United States, includes pharmaceuticals, physical therapy, and even medically prescribed spa treatments. Consumers have coverage that follows them from job to job, including any intervening periods of unemployment. Out-of-pocket costs are capped below the level where they could cause financial hardship. There is free choice of office-based physicians and ancillary service providers for ambulatory care. France spent 9.1% of its gross domestic product (GDP) on health care in 1991, similar to Canada (10.0%) and Germany (8.5%) but over 4 GDP percentage points less than the United States at 13.4%.1Yet life expectancy in France at 81.1 years for women and 73.0 years for men in 1991

To the Editor. —In response to Dr Lundberg's Editorial 1 on US health care system reform, his My Way seems closest to Senator Gramm's proposal, yet the Gramm proposal received bum marks on both cost control and promoting continuing quality, as well as other areas. Looks to me like we need some new analysts! As I understand it, the Gramm proposal calls for tax reform so that individuals can purchase tax-deductible catastrophic insurance and place the premium savings (catastrophic vs other insurance premiums) in tax-deductible, tax-free MSAs to spend on health care however they wish (including seeing specialists without a referral if they so choose). The policy belongs to the patients and not employers, so they cannot lose it by changing or losing jobs. Employers can still be expected to offer premium contributions, but the individuals choose and control their policies. Administration is a snap: most years, most patients will