Overview

Marion Ein Lewin

John Iglehart

The nation's search for a viable health care reform strategy has been accompanied by a deep, unabated interest in how other industrialized nations provide their citizens with universal coverage for comprehensive health care while spending considerably less per capita than the United States. Over the years, for example, many well-respected researchers and policymakers have argued that the United States would be wise to follow the lead of Canada with its government-based financing, global budgets, and fee-for-service delivery system. Others contend that Germany may be a more relevant model to emulate because it, like the United States, covers workers through the employment setting and maintains a role for insurers.

The ongoing interest in cross-national experience does not mean that the United States would be likely to adopt the health care system of any other country in total. There is every indication that America will pursue a strategy for health care reform based on the current system and that reflects the unique economic, social, and political dynamics of a large and heterogenous democracy. Other systems might have features that could advance our country's search for a more equitable, efficient, and effective health care enterprise. This volume, based on the 1992–1993 Richard and Hinda Rosenthal Lecture Series programs, provides particularly timely and useful information on a number of critical issues central to the current health care reform debate. Sections in this volume address how member states of the Organization for Economic Cooperation and Development (OECD) have approached the complex political challenges of pur-



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Changing the Health Care System: Models from Here and Abroad Overview Marion Ein Lewin John Iglehart The nation's search for a viable health care reform strategy has been accompanied by a deep, unabated interest in how other industrialized nations provide their citizens with universal coverage for comprehensive health care while spending considerably less per capita than the United States. Over the years, for example, many well-respected researchers and policymakers have argued that the United States would be wise to follow the lead of Canada with its government-based financing, global budgets, and fee-for-service delivery system. Others contend that Germany may be a more relevant model to emulate because it, like the United States, covers workers through the employment setting and maintains a role for insurers. The ongoing interest in cross-national experience does not mean that the United States would be likely to adopt the health care system of any other country in total. There is every indication that America will pursue a strategy for health care reform based on the current system and that reflects the unique economic, social, and political dynamics of a large and heterogenous democracy. Other systems might have features that could advance our country's search for a more equitable, efficient, and effective health care enterprise. This volume, based on the 1992–1993 Richard and Hinda Rosenthal Lecture Series programs, provides particularly timely and useful information on a number of critical issues central to the current health care reform debate. Sections in this volume address how member states of the Organization for Economic Cooperation and Development (OECD) have approached the complex political challenges of pur-

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Changing the Health Care System: Models from Here and Abroad suing major health care reform; how the reform movements in Europe have affected technologic innovation and diffusion; the role and infrastructure of primary care in the United Kingdom and its implications for strengthening primary care in the United States; and lessons on global budgeting from countries such as Canada and Germany and, closer to home, Rochester, New York, and its experiment with regional caps on hospital income. Jan E. Blanpain, the first 1992–1993 Rosenthal lecturer provides a highly informative overview of the three major “waves” of health care reform in Europe, beginning with the introduction and expansion of cradle-to-grave coverage through the 1940s; rising concerns over health care costs, inappropriate utilization, and excess capacity in the 1970s; and a number of reforms focused on encouraging better management tools and more efficiency in the 1980s. While America may be opting for a greater role for government under health care reform, countries like the United Kingdom and The Netherlands are moving to a greater reliance on market forces and competition. Dr. Blanpain's remarks underscore the many similar problems that both Europe and the United States face in their attempts to make health care more affordable and efficient—the impact of rising health care costs on national economies and budget deficits, an unbalanced supply of health care workers on both a functional and geographic basis, and growing concerns about the impact of cost containment on quality and access. Although Dr. Blanpain speaks to the value of international comparisons, he urges that analysts take into account the fact that foreign health care systems “are, on average, not well documented, extremely complex, and driven by unique local cultural and socioeconomic dynamics.” In a discussion on the development and diffusion of medical technology, Annetine C. Gelijns and Kathleen N. Lohr compare the European tradition of macromanaging the allocation of medical technology and other health care resources through public planning and regulatory tools to the United States' more micromanaged approach through financial incentives, utilization review, and other protocols for clinical decisions. Similar to Blanpain, Gelijns and Lohr point out that a nation's medical traditions, as well as its social and cultural variables, are important determinants of how technology and other medical resources are used and managed. In the current climate of seeking more cost effective approaches to health care delivery, almost all European nations have begun to invest more heavily in technology assessment and outcomes research. The authors suggest that a great deal of productive cross-fertilization could take place between the United States and the 44 states of Europe in the area of technology innovation and diffusion because they offer a wide

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Changing the Health Care System: Models from Here and Abroad range of political, economic, and social approaches as well as documentation on technology use, health outcomes, and expenditure data. There is wide agreement that any successful approach to U.S. health care reform must include a greater emphasis on primary care. In the United States, only 33 percent of physicians are in primary care specialties compared to 50–75 percent in other industrialized countries. Researchers and policymakers have long looked at the United Kingdom 's National Health Service for guidance on how to build a supportive, effective primary care training and delivery infrastructure, despite the major differences that exist between the two countries in the way health care is financed and organized. Jo Ivey Boufford provides a valuable, comprehensive primer on the key elements that differentiate a health care system based on primary care (the British model) from the U.S. system, which is focused on acute-care service delivery and medical education. Dr. Boufford discusses four key aspects of the British system that have particular relevance to current U.S. efforts to build a stronger foundation for primary care: (1) building a consensus on primary care and who should provide it; (2) the role of medical education and personnel planning to develop the appropriate health professions workforce; (3) the voices of patients and the public in a health care system; and, (4) defining a vision for what health care should accomplish. In response to Dr. Boufford's remarks, Dr. Alan Nelson summarizes the major dynamics in this country that have contributed to the decline in the attractiveness of primary care as a career choice for students and provides some illuminating suggestions for reversing the current trend. Dr. Nelson speaks to the unique feature of the U.S. health care system in which specialists provide primary care and ensure continuity of care for their patients. In moving toward a greater role for primary care, Dr. Nelson argues against mandating a solution, in favor of using financial incentives, curriculum reform, and, perhaps most important, changes in the practice environment to achieve desired objectives. In “Operating Under a Global Budget: Perspectives from the United States and Abroad,” Uwe Reinhardt describes the gradual but inexorable shift from expenditure-driven financing of health care towards budget-driven delivery of health care in the form of global budgeting or expenditure targets. Since the mid-1970s most of the industrialized world has attempted to shift toward budget-driven health care delivery with varying degrees of success. Because global budgeting is so politically contentious, the Clinton administration has selected managed competition as the vehicle for health care reform in the hope that market forces with some regulatory components can keep expenditures under control. Dr. Reinhardt argues that although managed competition has enormous intuitive appeal, it is to date a theoretical blueprint without a full-fledged,

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Changing the Health Care System: Models from Here and Abroad real-life counterpart. However, he suggests that a global budget could be added at a later date to the framework of managed competition if health care costs continue to accelerate at an unacceptable rate. Uwe Reinhardt points out that global budgeting is still in its infancy in the United States, and lacks an infrastructure for effective implementation. A number of interesting additional perspectives on global budgeting are provided by Robert Blendon, Vickery Stoughton, James Bentley, and Paul Griner. Robert Blendon spoke about an article he coauthored that examined global budgeting from the perspective of practicing physicians in Western Germany, Canada, and the United States. Vickery Stoughton addresses the effects of global budgeting on the Canadian health care system, particularly as it relates to resource allocation, waiting times, and the availability of certain technologies. James Bentley speaks to the issue of global budgeting from the perspectives of the hospital sector. He notes that some forms of global budgeting are already in existence through programs operated by the Veterans Administration, the Public Health Service, and to some degree, Medicare and Medicaid. Mr. Bentley suggests that for global budgeting to succeed, greater emphasis must be placed on the delivery system to provide the structure, and on information and shared financial interests to provide the required framework. During the year in which these lecture programs were conducted, the dialogue and possible agenda for health care reform has moved forward at unprecedented speed. In November 1992, Bill Clinton was elected president on a platform dedicated to the goals of universal coverage and lowering the rate of health care costs. This new, sharpened focus on reform adds to the value and timeliness of the presentations included in this volume. The topics addressed in these pages help to inform and illuminate issues at the heart of current efforts to reshape and improve America's health care system.