Overview and Introduction
Donald E. Wilson, M.D., M.A.C.P.
Dean, School of Medicine, University of Maryland at Baltimore
During the last three years, no subject has generated more interest, more debate, or more activity than our nation's health and health care delivery system. Industry began to see a third of its expenditures used to provide health benefits to its employees. Consumers grew alarmed by health insurance premiums that escalated rapidly to thousands of dollars a year and locked them into their current position due to a lack of portability of coverage for preexisting conditions.
The nation saw its health bills consume 14 percent of the gross national product, or $900 billion. However, there is an interesting paradox:
most Americans have access to unparalleled state-of-the-art health care and are satisfied with the treatment that they receive;
people from all over the world come to the United States in search of the most advanced medical procedures and technology;
our medical education system produces some of the world's finest physicians and scientists; and
the United States is a world-recognized leader in biomedical research. Babies weighing less than one pound now survive and grow to become healthy children, and we have made remarkable progress toward unlocking the mysteries of the human genome.
At the same time, however, 40 million Americans are without health insurance, and another 30 million Americans do not have adequate health insurance. We have seen the reemergence of preventable diseases such as polio and measles, and the continuation of devastating but preventable disabilities caused by lead poisoning, the return of tuberculosis, and a veritable explosion of sexually transmitted diseases.
Consumers became confused or ambivalent: thankful for, but expecting and demanding, that high-technology subspecialty care be available when they needed it, yet also concerned about their ability to afford and obtain general care that attended to their health as well as their diseases. Conventional wisdom indicated that something needed to be done.
The year 1994 was one of great health care nonreform. Although national legislation was not enacted, states began to seek ways to deal seriously with the issues—primarily the cost, but also the quality, of care.
Medical schools were told that the country did not need or want the current mix of physicians. Indeed, in some instances, public institutions were told that their continued funding was dependent upon a certain percentage of their graduates choosing primary care specialties. More important, in a climate increasingly intolerant of regulation but enormously supportive of cost reduction, industry took charge.
In 1995 we have witnessed dramatic changes in the delivery of health care and in the payment for health care services. Managed care and capitation have expanded greatly. The State of Maryland, which was in the early stages of managed care penetration 2 years ago, has moved to among the top four regions at the present time. Certain types of physician specialists have found much less demand for their services and a corresponding decrease in their compensation. Academic health centers are scrambling to maintain their enterprises and fulfill their missions, and are confused about what is a successful strategy.
Most recently, some experts and policymakers have begun to question whether the changes are too rapid; whether they may have long-term negative effects on our educational, research, and discovery abilities; and whether the changes that have occurred are indeed providing affordable, high-quality health care. Will we be able to solve the problem of people who are uninsured? Will the poor have access to appropriate health care?
As is usually the case, before a problem can be solved it must be defined. What are the needs of our population, and what will be the major problems in the future? What new programs can best be devised to meet these needs? What information is necessary to assess these needs, and how do we communicate this information effectively? Can we develop a reasonable payment system that adequately compensates health care providers and, at the same time, motivates them to use resources judiciously, engage in health care rather than disease treatment, and keep the welfare and well-being of patients at the forefront of their activities? In the current frenzy of competition, will we be able to sustain our premier educational and research institutions in order to support the training of providers and investigators and the development of new clinical and technological discoveries? Should there be a significant downsizing of the academic enterprise, and if so, how should we accomplish this? How do we utilize most effectively the talents of an increasingly diversified, multidisciplinary health work force to best provide affordable health care to the patients?