Could the American Health System Become the Best in the World?

Josep M. Picas

The title of this paper is the same as one recently published in the "Perspective" section of The New England Journal of Medicine (NEJM), "From Last to First. Could the U.S. Health Care System Become Best in the World?" This article seemed to me to be an interesting example of introspection and critical analysis, and at the same time an excellent formulation of future challenges. I must confess that I feel admiration and envy for these types of approaches and advances that we frequently observe in the Anglo-Saxon environment.

In summary, the article is based on a report from the Common-wealth Fund which compares health expen-diture and results across several countries of the world with a high economic level. It’s said that in the United States, despite offering a high level of ad-vanced, specialized technical treatment, the results, from the populations’ point of view, leaves much to be desired. The authors attribute the causes of the problems to several factors:

• Deficiencies in accessibility in its various nuances (linked to the subject of coverage).
• Necessary commitment to primary care (expose their hope in the Medical Home).
• Administrative inefficiency (linked to payment systems).
• Inequity in the provision of services (associated, among others, with the necessary commitment to increase the financing of social services).

They end the article with the proposal to overcome these challenges and place their hopes on maintaining and improving their health laws despite of the existing threats.

But the aspect that more reflection provokes is that this article appears in a moment of maximum confusion. In particular, if we want to predict how the American health system will evolve, as in many other fields, it will suffer from the actions of the current presidency. In any case, it seems to me of interest to comment that the various attempts at repeal & replace the so-called Obamacare have failed until now, even with the opposition of prominent Republican senators. Many of these attempts relate to the level of coverage and to insurance aspects, but not so much to the organizational model.

At this level, it should be noted that the number of ACOs (accountable care organizations, probably the paradigm of integrated health systems) has continued to rise and their two best-known programs have expanded their success: Medicare Shared Savings recently communicated a total savings of 652 million dollars in 2016 (for example, the Cleveland Clinic ACO has saved 42.2 million, of which 19.9 million will be returned) and the other program, Bundled Payments ), continues to move forward with nuances, especially by introducing concepts related to value payment, led, among others, by Michael Porter.

Success has impacted most global health systems, for example in New Zealand (see "Developing accoun-table care systems, Lessons from Canterbury, New Zealand"). And perhaps the most surprising case is Germany, where, after the success-ful and little-known Gesundes Kinzigtal, OptiMedis AG is expan-ding by applying the model in the Netherlands and even in the United Kingdom.

In order to finish and emphasize this approach to "wanting to be" despite unfavourable environments, two recent documents are advisable for people who may be interested. In one of them, from the National Academies: Global Health and the Future Role of the United States, a large number of authors are positioned in the face of health globalization, and in another, published by NEJM Catalyst under the title The New Marketplace of Health Care: Impacts and Incentives of Payment Reform brings together a collection of articles and expert conversations that lead the reform of the payment system along with clinical practitioners, among many other relevant professionals.

A final comment is that, sadly, our country is not mentioned in this article of the NEJM and that the detail of our involvement in Global Health is insignificant (0.12% of GDP and 25th place among 28 countries, when the average is in 0.41% and the UN target is 0.7%). Maybe someday someone would have to pose some questions.