Why the U.S. Health Care System Lags Behind: A Call for Equitable, High-Value Care
The U.S. trails other wealthy nations in health care value. Compared to its peers, the U.S. faces higher health care disparities, avoidable hospitalizations, maternal morbidity and mortality, and a shorter life expectancy, all while incurring the world’s highest health care costs. U.S. health care delivers suboptimal value and equity.
Understanding Health Care Value and Equity
The Centers for Medicare and Medicaid Services defines health care equity as “ensuring everyone has a fair and just opportunity to attain their optimal health, regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, or other factors affecting access to care and health outcomes.” Patients experience equity based on perceived fairness in care processes and outcomes. Health care value and equity are inextricably intertwined, representing cornerstones of high-value, equitable care.
AcademyHealth, funded by The Donaghue Foundation, assembled a diverse multistakeholder group to develop a research agenda toward achieving high-value, equitable care. The group developed a driver model to guide the assessment of evidence and gaps in the evidence. The first of the five drivers (listed below) is a “Fair and Just Culture of Whole-Person Health for All.” The summary report on the research agenda and drivers can be accessed here.
Key Drivers for Achieving High-Value, Equitable Care:
- A Fair and Just Culture of Whole-Person Health for All: The health care system is aligned to provide holistic care that addresses patients’ overall health and wellbeing
- Care That is Accessible to All Patients: All patients are able to receive the care they need.
- Health System Centered Around Primary Care: Primary care serves a key role in providing continuous and coordinated care within the broader health system
- Adequate Health System Capacity to Deliver Care: Health care organizations have appropriate policies, technologies, staffing and other resources to support patient needs.
- Health System Accountability for Outcomes: Health care organizations are held accountable to policies, payers, communities and patients for health outcomes.
A Fair and Just Culture of Whole-Person Health for All
Seventy-five years ago, the World Health Organization expanded the concept of health beyond a biomedical definition to include physical, mental, and social well-being. Yet, the biomedical “cultural imperative” persists today with health care payment based on the presence of disease, the performance of procedures, and treatment with drugs and devices. It reinforces an inequitable, often dehumanizing commodity-based health care system that fails to enable individuals, families, and communities to optimize their health and well-being.
A just, whole health model addresses these deficiencies. It is respectful and collaborative, centering care around what matters to the person/family, allowing investment in people’s capacity for healing and health. This model offers enablement for wellness, health optimization, disease management, and promotion of well-being. The word “culture” emphasizes that this health care transformation requires a culture change. The word “just” signals the critical role of equity in supporting whole health across the health care continuum from prevention, treatment, and disease management to end-of-life care. Achieving this transformation requires progress in the four other drivers. By integrating these elements, the whole health model aims to create a high-value, equitable health care system that rectifies current inequities and inefficiencies.
Research to Inform Novel Health Care Models
Research is needed to inform operationalization of these five drivers. This requires substantial investment in pragmatic research designed to demonstrate real-world generalizability, in addition to major investment in implementation research designed to promote the uptake and sustainability of high-impact, evidence-based interventions, including those that address equity. Research on optimal, equitable strategies for enabling people, families, and communities to live healthier lives and delay disease onset is foundational to improving population health, equity, and minimizing the costs of preventable disease and disparities in disease incidence. Access is a multidimensional construct that includes accommodations for affordability, distance, physical accessibility, language, and culture. Research is needed on addressing all dimensions in addition to fair and equitable access for those without insurance. Research on the design, implementation, and sustainment of high-quality, high-equity primary care models is lacking underscoring the need for research in this area. Addressing capacity for a high-value equitable system requires identifying core resources needed for an high-value, equitable system. One approach is demonstration models built from the ground up based on global payments that offer the flexibility for redesign. Accountability for outcomes requires clarifying and operationalizing core outcomes related to whole health, i.e. non-traditional quality measures, e.g. health outcomes including improved functioning or proxy measures for health such as the Life’s Essential 8, well-being, and community health. The development of reliable, actionable whole health accountability measures is essential to progress towards a high-value equitable system.
Novel Research Partnerships
Three transformative changes in research partnerships are needed. First, existing funders must generate the evidence to inform new models. Second, much greater coordination between health systems and payers is needed in conducting pragmatic research including clinical trials. Third, equitable, sustainable models of research must be deployed, engaging communities in the entire process of designing, implementing, and evaluating models that address community-identified health problems. These fundamental changes involving the “what” and “how” of research are vital to health care transformation.
Read the first and second blog posts in this five-part series.