A Successful and Sustainable Health System — How to Get There from Here — via NEJM

This is only a fragment of a very interesting essay on the current pitfalls of US health system, but one can see lessons to Brazil, as well. The entire text is worth a read.

In his famous essay on Tolstoy entitled “The Hedgehog and the Fox,” Isaiah Berlin compared a number of historical figures to one or the other animal. Foxes know many things, whereas the hedgehog knows one big thing. Tolstoy, concluded Berlin, was a fox masquerading as a hedgehog: although he believed that history demanded a unifying theme, he could not resist his tendency to see many threads rather than one big cord.
To achieve a successful and sustainable health system, we must be able and willing to try many different things. But therein lies a unifying idea: do many things. No single stroke will solve this problem. A successful and sustainable health system will not be achieved by supporting prevention, it will not be achieved by championing competition, it will not be achieved by comparing the effectiveness of different practices, it will not be achieved by striking commercial influence from professional decision making, it will not be achieved by changing the way we pay doctors, and it will not be achieved by just reengineering the system. It requires all these changes and more. We need the cleverness of the fox and the persistence of the hedgehog. We must be willing to adopt many strategies and use them to reach one big goal.

Sources of Inefficiency in U.S. Health Care

	• Payment for wrong outputs (units of service rather than episode of illness, health outcomes, or covered lives)
	• Financial incentives that reward inefficiency (complications or readmissions)
	• Lack of price information and incentives for patients
	• Indifference of providers to induced costs
	• Dysfunctional competition rather than performance-based competition
	• Lack of personal or professional ethos to care about societal costs of health care
	• Failure to take full advantage of professional skills of nurses
	• Lack of uniform systems and processes to ensure safe and high-quality care
	• Uneven patient flows, resulting in overcrowding, suboptimal care, and waste
	• Insufficient involvement of patients in decision making (as in end-of-life care)
	• Insufficient attention to prevention, disparities, primary care, health literacy, population health, and long-term results
	• Fragmented and uncoordinated delivery, without continuity of care
	• Lack of information on resource costs, performance, comparative effectiveness, quality of care, and health outcomes
	• Scientific uncertainty about effectiveness and cost, especially of newer tests and treatments
	• Cultural predisposition to believe that more care is better
	• Administrative complexity of coping with multiple forms, regimens, and requirements of different insurers
	• Rewarding of inventors and entrepreneurs for possible performance advantage more than for significant savings in overall system cost
	• Regulatory regime that can only retard and not accelerate innovation
	• Insufficient reliance on competitive bidding for drugs and devices
	• Distortions resulting from fraud, conflict of interest, and a dysfunctional malpractice system

Potential Uses of Health IT

	• Personal medical records
	• Personalized health reminders and follow-up
	• Personal health, diet, and activity monitoring and motivation
	• Pre-degree and continuing medical education
	• Real-time clinical decision support
	• Remote professional consultation and care
	• Monitoring and advising of patients with chronic disease
	• Quality assurance
	• Performance assessment of providers and institutions
	• Comparative outcomes research
	• Matching of potential participants to clinical trials
	• Monitoring for safety (or unanticipated benefits) of drugs, devices, diagnostic tests, surgery, and other treatments
	• Enhanced peer-to-peer and professional–patient support
	• Comparative health assessments across populations, communities, cities, and states
	• Public health surveillance for disease outbreaks, environmental risks, and potential bioterrorism

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Source Information

From the Institute of Medicine, Washington, DC.
Address reprint requests to Dr. Fineberg at the Institute of Medicine, 500 Fifth St., NW, Washington, DC 20001.

Link to the full text: http://bit.ly/xPLo3A

A Successful and Sustainable Health System — How to Get There from Here — NEJM