US health care reform: reality and implications for Asian health care providers, administrators and policy makers

Abstract

The US health care delivery system is a dysfunctional mess [1], lacks a cohesive and affordable national plan, is addicted to technology and gadgets, has a fee-for-service reimbursement structure which discourages medical students from going into primary care specialties, and suffers under the weight of an iron quadrangle: the health insurance industry, politicians, hospitals, and the pharmaceutical industry. This quadrangle, while giving lip service to health care reform, is fighting to maintain the status quo and its own bottom line. While the medical profession may be losing the ‘war’, it has its own shortcomings, such as overspecialization, and the emphasis on ‘half-way’ technologies [2] rather than those interventions that were proven effective by randomized clinical trials [3]. In addition, the proliferation of subspecialty societies, largely dedicated to promoting their own interests, has added to the challenge of meaningful reform. This situation is another example of the ‘Tragedy of the Commons’: finite resources vs unlimited demand [4]; a concept also described earlier by Thucydides and Aristotle [5]. Although there is a long history of reform efforts [6], the current ‘non-system’ has been remarkably resilient and resistant to change [7]. During the 2008 election campaign, neither candidate proposed a meaningful major reform plan. The American congress is beholden to too many special interests, has lost the respect of the American public and has so far proven inept and inert. The United States cannot afford to continue with this $2 trillion dinosaur without major reform. Patchwork fixes, such as electronic medical records and tort reform [8, 9], will not suffice. Health maintenance organizations (HMO’s) and managed-care organizations have not had significant impact in spite of early successes. Health care has been transformed from a public service into a business commodity, paying obscene salaries to greedy senior executives [10]. The US system is tilted highly to the expensive delivery of health services at personal and public expense in the form of reduced pay and benefits and high-cost insurance and taxes [11], when common sense should dictate otherwise. As Emmanuel and Fuchs have described, we in the U.S. have produced ‘A Perfect Storm of Overutilization’ [12]. The pendulum must move back to the center, with a balance of affordable insurance for all, primary care as the underpinning for people, reimbursement systems which reward primary care givers fairly, and ‘Taming the Technology Beast’ [13]. No amount of effort at cost control, primary care, electronic medical records, etc. will succeed unless a more rational system of technology development and distribution is implemented, including the study of safety and other unintended consequences [13]. The implications for Asian health care delivery seem clear. “Do not follow the US example”. Work toward a rational balance (diagonal) of primary (horizontal) and speciality (vertical) care [14-17]. And remember that without proper use of effective technologies (immunization, safe drinking water and sanitation), you will fail. Here, ‘vertical’ applies to aiming for disease-specific results (specialization), ‘horizontal’ applies to broader improvement in health systems, ‘diagonal’ applies to improving the broader health system to achieve disease-specific results [14-17].