ACP's plan to overcome obstacles to good health care

ACP has released proposals to achieve universal coverage, lower out-of-pocket costs, reduce wasteful administrative spending, improve payment and delivery systems, and overcome social and economic barriers to care. Called “Better Is Possible: ACP's Vision for the U.S. Health Care System” and published Jan. 21 as a supplement to Annals of Internal Medicine, these proposals make the case for fundamental reforms of the U.S. health care system.

The four position papers included in the supplement cite hundreds of studies showing that the U.S. spends far more on health care than other well-off countries, yet has poorer outcomes for most treatable medical conditions. Tens of millions of people have no health insurance coverage at all. Many more with insurance still can't afford medical care because of high deductibles and excessive prices.

The U.S. spends far more on health care administration than other industrialized countries. Many Americans have poorer health because of social determinants or because of discrimination and disparities in care. The way health care is paid for and delivered in the U.S. often creates incentives that are at odds with what's best for patients.

But it's not just academic studies that tell us better is possible; it's the everyday experiences of internal medicine physicians. ACP's vision for a better U.S. health care system offers solutions to the biggest obstacles internists experience in helping their patients get the care they need.

Lack of insurance. Internists know that patients without health insurance often forgo preventive services and wait to see a doctor until they are very sick. When they do see a physician, they delay or forgo filling their prescriptions because they can't afford it. For many patients, having insurance can be a matter of life and death. ACP's vision for a better system would guarantee that all Americans have coverage for the care they need, regardless of where they live and work, their income, or their health status, through a single-payer system or through a publicly funded plan that would be made available to anyone along with a choice of regulated private insurance.

High deductibles. Internists know that even when their patients have insurance, they often can't afford care because of high deductibles and copayments. ACP's vision proposes that deductibles and copayments that stand in the way of high-value care, like primary care and prevention, be eliminated and, if copayments and deductibles are required for some services, that they be capped based on a person's income.

Administrative costs. Internists know that the U.S. wastes hundreds of billions of dollars annually to pay for the most intrusive, byzantine, and administratively heavy health care system in the world. This is largely because each payer has its own unique rules, formularies, documentation, and preauthorization requirements that need to be followed for care to be authorized and covered. A single-payer system as recommended by ACP would eliminate the multiple and conflicting administrative rules imposed by insurers and redistribute administrative spending to patient care. Alternatively, a public choice system could also reduce administrative spending and paperwork, but not by as much as single payer.

Excessive prices. Internists know that excessive prices for prescription drugs and hospital stays make care unaffordable for many patients and that it's nearly impossible for patients to know in advance what they'll be charged for hospital care or how much their insurer will pay toward it. ACP's vision proposes that excessive prices be lowered for prescription drugs, that hospitals be paid standardized rates within a global budget, and that patients be provided with transparent information on what they'll be charged and what their insurance will pay before receiving care whenever possible.

Lack of support for primary and comprehensive care. Internists know that having a primary care physician is the foundation of good medical care, leading to lower costs and better outcomes, and that patients with complex chronic illnesses especially benefit from the primary, preventive, and comprehensive care provided by internal medicine specialists.

Yet the U.S. undervalues and underinvests in primary and comprehensive care, creating access problems for millions of patients. ACP's vision calls on the U.S. to substantially increase spending on primary care, to completely eliminate disparities in payment between cognitive services and procedures, and to better fund the training of internal medicine specialists and other primary care physicians.

Payment systems that aren't aligned with patients' needs. Internists know that the movement to value-based payment, while mostly well intentioned, often gets in the way of good patient care. It requires them to report on check-the-box performance measures that do not result in better outcomes but instead take their time away from patients. ACP calls for systematic changes in payment and delivery systems to center on the needs of patients, eliminate check-the-box reporting, and encourage use of measures for internal quality improvement activities.

Dysfunctional electronic health records (EHRs). Internists see the obstacles created by EHRs that do not give them the information they need to support better patient care while making them spend hours clicking boxes for purposes of documentation, at the expense of time with patients. ACP's vision calls for redesign of EHRs and other health information technologies to help physicians provide better care to patients, instead of meeting the documentation demands of payers.

Social determinants and discrimination. Internists see the heartbreak of patients in poor health because of the social, environmental, and economic conditions in which they live or because of discrimination and disparities in care. ACP's vision calls on the U.S. to gain a better understanding of social determinants, to implement policies to overcome them, and to end discrimination and disparities in care based on a person's personal characteristics.

The title of ACP's vision for U.S. health care begins with “Better Is Possible” for good reason. ACP knows better is possible because that's what the evidence shows. But paramount are the experiences of ACP members with a U.S. health care system that is failing their patients. They tell us better is possible, and ACP's vision for U.S. health care points the way to it.