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Preparing for the Future: A 2020 Vision for American Health Care

Davis, Karen PhD

National Policy Perspectives

Karen Davis is president of The Commonwealth Fund, a private foundation based in New York City. This essay is adapted from an article by Karen Davis, Cathy Schoen, and Stephen C. Schoenbaum that first appeared in the December 11–25, 2000, Archives of Internal Medicine.



As we enter the 21st century, our health care system has the potential to deliver to every American the highest-quality care. But to realize this potential, we need to redesign the system. A growing federal budget surplus can help us address the most fundamental flaw—the lack of affordable and automatic health insurance coverage for all. Advances in information technology, new quality-improvement techniques, and patients' desire to be active partners in their care can also aid us as we seek to redesign the U.S. health care system to improve the quality of care and increase responsiveness to patients. Leaders of academic medicine need to become deeply engaged in this process. Visionary leadership in redesigning systems of care, training a new generation of clinicians, and advocating policy changes that reward quality and make care accessible is essential to create a high-performance system.

Now is the time to act. The federal budget surplus is projected to be $5.6 trillion over the next ten years. More than $1 trillion of this is directly related to savings from Medicare and Medicaid. The 1997 Balanced Budget Act sought fiscal triage for deficits that seemed to be metastasizing out of control. Part of the treatment was to cut payments to Medicare providers and raise premiums for beneficiaries. But we underestimated the magnitude of savings. At the same time, we underestimated the drop-off in Medicaid coverage, as welfare reform took hold. Finally, we underestimated the strength of our economy. Instead of balancing the budget we generated a huge surplus. As we deliberate how best to allocate it, we should give serious consideration to reinvesting a generous portion of it in health care. Health care should be on a par with tax cuts, reducing the federal debt, and assuring the future solvency of Social Security and Medicare.

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We need a bold approach—a 20/20 vision for U.S. health care by 2020—one that does justice both to the magnitude of the problems in the current system and to the creativity and commitment of health care leaders and professionals. Such an approach would have five features: (1) automatic and affordable health insurance coverage for all; (2) access to health care for all; (3) patient-responsive health care; (4) information-driven health care; and (5) commitment to quality improvement. These goals may not be achievable in the next four years, but they can be in place within a generation.

The absence of health insurance coverage is the single most important reason Americans fail to receive necessary health care. It is at the root of the complexity of our system, causes fear and delay on the part of patients, and makes it impossible for physicians to provide adequate care. It also puts tremendous financial stress on the academic health centers and other safety net institutions struggling to give care to the needy and to those with conditions that require specialized services.

The task of providing easy access to quality care is not as daunting as some make it seem. One approach would be to cover all workers automatically under employer plans unless they opted out. Tax credits or other incentives could be used to ensure affordability. Small businesses and the self-employed could be permitted to purchase coverage through the Federal Employees Health Benefits Plan. Together, these measures could reduce the number of uninsured by up to 17 million. Most of those remaining uninsured—the poor and those outside the workforce—could be reached through incremental expansions of Medicare, Medicaid, and the Children's Health Insurance Plan (CHIP).

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A health system worthy of a new century requires more than just an insurance card and defined benefits. There also should be an easy entrée into the system for every American. In an ideal world, every person would select a personal physician or nurse-clinician to serve as his or here advocate, helping to ensure regular preventive care and appropriate treatment for acute, chronic, and emergency conditions. This personal clinician would also be responsible for coordinating a patient's care across sites and among providers, a vital task for which academic medicine does not yet prepare students.

Ready access to a personal clinician requires rethinking and re-engineering current approaches to providing “visits.” Understanding that patients want information and that information itself is care, part of the responsibility of a personal clinician is being available to patients—when patients need to see them and when they want information by phone, e-mail, or the Internet. “Open access” models of scheduling that provide care and information when patients need it lead to better care.

Information for patients, clinicians, and health care organizations is key to a high-performance health care system. Information systems should be designed to help patients choose the physicians best matched to their needs and preferences. Such systems would provide data about physicians' credentials, office locations, and hours of practice, as well as information about age, gender, race, and ethnicity. Information about quality of care—including reports by patients and peer assessments of physicians' practices—should also be made available.

Information systems can also help coordinate care across sites of care by facilitating the exchange of information among primary care and specialist physicians, hospitals, labs, and pharmacies. Electronic medical records and computerized physician order-entry systems have great potential to reduce errors, improve efficiency, eliminate duplication and wasted time, and improve satisfaction on the part of patients and clinicians alike. Facilitating patients' access to their own medical records and information about self-care, medications, and treatment plans helps patients become active partners in their care, as well as allies in preventing medical errors.

In today's complex health care system clinical decision-support tools need to be accessible to physicians—whether through hand-held computers or desktop computers. Quick access to medical information and alerting systems that raise warning flags or prompt physicians about departures from accepted guidelines or protocols are all part of state-of-the-art care.

On the quality front, the U.S. health care system has allowed short-term considerations of cost cutting to get in the way of doing what is best for patients. We need to shift from a model of competition to one of collaboration. For example, virtual peer networks could serve as effective mechanisms for comparing quality outcomes, identifying best practices, and adopting improved processes of care. Formal training and work on quality improvement, such as occurs through the Breakthrough Series, can also be effective in achieving rapid change in practices and results.

A 2020 vision for U.S. health care embraces a commitment to quality improvement by every one of the nine million people working in the health care sector—which is fortunate to attract people truly committed to caring and curing. Physicians, other professionals, hospitals, and other health institutions need to make quality the number-one priority. A genuine commitment to quality improvement, including periodic board recertification and peer assessment for physicians and other clinicians, public release of quality information, and participation in quality improvement and patient-safety initiatives, must become commonplace in U.S. health care. Professionalism values accreditation not only of institutions but also of practicing clinicians.

Academic health centers have an obligation and opportunity to incorporate quality-improvement techniques into all of their activities and processes—teaching, patient care, and research. By 2020, they should be as recognized for their commitment to quality as they have been in recent years for their commitment to technologic advances and care of the indigent.

A commitment to quality also means arguing for better rewards and resources to make the investments required to achieve a high-performance health care system. Neither managed care nor traditional fee-for-service care can motivate the transformation of U.S. health care to achieve Six-Sigma levels of quality. New approaches that reward quality, promote investment in information technology, and support collaboration are needed to reinforce clinicians' professional commitment.

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When we look ahead a generation to the year 2020, we need clinicians and health care leaders who have the skills and training that capitalize on the potential for positive change presented by emerging quality-improvement techniques and advances in information technology and evidence-based medicine. We need clinician-managers, people motivated to provide the best care and trained to bring modern management techniques to providing patient-responsive care.

The human side of medicine is equally important. American society is rapidly becoming more diverse. Cultural competency—being sensitive to patients' racial and ethnic diversity—is part of providing high-quality care. Cultural competency needs to be integrated into all aspects of clinical skills—patient interviews, examinations, and treatment plans. The criteria for admission to medical school should take into account humanistic qualities and logical decision-making skills as well as academic achievement. A high-performance health care system as envisioned here is too complex to rely on individual decision makers and memory. Tomorrow's clinicians and managers need to be comfortable working in teams, with systems that provide support and prevent error.

We've gone through two decades of resource constraint in American health care. Managed care has failed to fulfill its promise of better care at lower cost and has led to great frustration among clinicians and health care leaders. We need to create a new system, not return to the old one, which was inefficient, wasteful, and excessive. We need to strive for a system that guarantees access to high-quality health care to every American, a system in which everyone can afford comprehensive health insurance, a system that mobilizes the latest information technology to improve coordination of care and help patients become partners in their treatment.

We have the economic and intellectual resources to create such a system. In doing so we will earn for ourselves a decenter society, a healthier people, and an even stronger economy. Working together, health care professionals, patients, and their families can create a system that provides the best that modern health care has to offer.

© 2001 Association of American Medical Colleges