PHILADELPHIA — In order to evoke a true transformation, the U.S. health care system needs an audacious goal, one equivalent to President Kennedy’s call for a man on the moon in 1962, says Ezekiel J. Emanuel, MD, PHD, Diane v.S. Levy and Robert M. Levy University Professor and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. In a Viewpoint published in the November 13 issue of JAMA, Emanuel recommends limiting the rate of per capita health care cost increases to that of the U.S. economy as a whole as measured by the growth of the U.S. gross domestic product (GDP).
The article identifies several reasons for adopting this as a national goal, invoking the criteria established by management author Jim Collins for what he dubbed a big hairy audacious goal. First, it is clear. Second, it is easily measurable. Third, it has a well defined timeframe that aims well into the future. Fourth, it is sufficiently challenging to be a motivator of action. And finally, it has a reasonable probability of success while still being difficult.
Emanuel writes that universal health care coverage was at one time the U.S. health system’s audacious goal. But, he says, while that the Affordable Care Act was transformative for the nation’s political system, it will not be transformative for the health care system itself.
Noting that Massachusetts, Arkansas and Maryland have already adopted goals limiting in-state health care cost growth to the growth of their respective state economies, Emanuel says a similar national goal will result in improved quality of care. But it will “require turning care delivery upside down.” Specifically, he writes, “instead of focusing on care in the hospital, more outpatient monitoring … and more interventions at home” will be necessary to keep patients “healthy and with fewer emergency department visits and hospitalizations.”
Tools needed to achieve the goal include “team-based care coordination between office, hospital, pharmacy, and home; reducing the use of inappropriate interventions; and electronic records with real-time tracking of leading physiologic indicators.”
In the piece, Emanuel recognizes that some will challenge his recommendation as being “too money oriented,” preferring a more quality-oriented goal instead. But, he suggests that such goals have inherent difficulties in meeting Collins’ criteria. For example, aiming for the U.S. to have the “best health care system in the world” is insufficiently measureable. Eliminating hospital-acquired conditions, while valuable, is not sufficiently transformative of the full health care system, including outpatient care.
In contrast, reigning in the rate of per capita health care cost is: clear and easily measured; its time frame is sufficiently long-range – at least seven years hence; it is doable but sufficiently challenging, only having been achieved a few times in the past fifty years, and most recently nearly twenty years ago. Most importantly, Emanuel says, “if the effort is successful, the entire health care system will have been transformed.”
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