Government panel suggests four action priorities
Editor’s note: From “Vital Directions for Health and Health Care: Priorities from a National Academy of Medicine Initiative,” National Academy of Sciences.
The United States is poised at a critical juncture in health and healthcare. Powerful new insights are emerging on the potential of disease and disability, but the translation of that knowledge to action is hampered by debate focused on elements of the Affordable Care Act, which, while very important, will have relatively limited impact on the overall health of the population without attention to broader challenges and opportunities.
Fundamental challenges
- Persistent inequities in health. In spite of the United States’ great investment in healthcare services and state-of-the-art healthcare technology, inequities in healthcare access and status persist across the population and are more widespread than in peer nations. Over the past 15 years, individuals in the upper income brackets have seen gains in life expectancy, while those in the lowest income brackets have seen modest to no gains.
- Rapidly aging population. By 2060, the number of older persons (ages 65 years or older) is expected to rise to 98 million, more than double the 46 million today. In total population terms, the percentage of older adults will rise from 15 percent to nearly 24 percent. As more and more people age, rates of physical and cognitive disability, chronic disease, and comorbidities are anticipated to rise, increasing the complexity and cost of delivering or receiving care.
- New and emerging health threats. S. public health and preparedness has been strained by a number of recent high profile challenges, such as lead-contaminated drinking water in several of our cities; antibiotic resistance; mosquito-borne illnesses such as Zika, Dengue, and Chikungunya; diseases of animal origin, including HIV, influenzas, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome-Coronavirus (MERS-CoV), and Ebola; and natural disasters, such as hurricanes Sandy and Katrina. The emergence of these threats, and in some cases the related responses, highlights the need for the public health system to better equip communities to better identify and respond to these threats.
- Persisting care fragmentation and discontinuity. While recent efforts on payment reform have aimed to advance coordinated care models, much of healthcare delivery still remains fragmented and siloed. This is particularly true for complex, high-cost patients – those with fundamentally complex medical, behavioral, and social needs. Complex care patients include the frail elderly, those who are disabled and under 65 years old, those with advanced illness, and people that have multiple chronic conditions. High-need, high-cost patients comprise about 5 percent of the patient population, but drive roughly 50 percent of health care spending.
- Health expenditure costs and waste. It is widely acknowledged that the U.S. is experiencing unsustainable cost growth in healthcare: spending is higher, coverage costs are higher, and the costs associated with gaining access to the best treatments and medical technologies are similarly increasing. In 2015, health care spending grew 5.8 percent, totaling $3.2 trillion or close to 18 percent of GDP. Of that, it has been estimated that approximately 30 percent can be attributed to wasteful or excess costs, including costs associated with unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities, and fraud.
- Constrained innovation due to outmoded approaches. The U.S. has long been a global leader in biomedical innovation, but our edge is increasingly at risk due to outdated regulatory, education and training models. In the drug and medical device review and approval process, uncertainty and unpredictability around approval expectations add complication, delay, and expense to the research and development process, and can translate to a disincentive to investors. Simultaneously, there are concerns that the movement toward population-based payment models may stifle innovation and patient access by placing excessive burden on manufacturers to demonstrate the value of their products upfront in approval and reimbursement decisions.
Tools for improvement
The good news is that the nation is equipped to tackle these challenges from a position of unprecedented knowledge and substantial capacity. Following are several of the crosscutting opportunities for progress identified over the course of the initiative and its work.
- A new paradigm of healthcare delivery and financing. Under fee-for-service, healthcare services are paid for by individual units, incentivizing providers to order more tests and administer more procedures, sometimes irrespective of need or expected benefit to the patient. In contrast, value-based, alternative payment models (APMs) incentivize providers to maintain or improve the health of their patients, while reducing excess costs by delivering coordinated, cost-effective, and evidence-based care.
- Fully embracing the centrality of population and community health. It is increasingly acknowledged that effective measures to improve health status and health outcomes over groups and over time require tending to the conditions and factors that affect individual and population health over the life course, including social, behavioral, and environmental determinants.
- Increased focus on individual and family engagement. Today, there is increased focus on expanding the roles of individuals and families in not only designing and executing healthcare regimens, but in measuring progress, and in developing and testing new and innovative treatments.
- Biomedical innovation, precision medicine, and new diagnostic capabilities. Breakthroughs in biotechnology have generated new treatments and cures for diseases that were previously untreatable or could only be symptomatically managed, such as cardiovascular disease, HIV, and Hepatitis C. Diagnostics have also become more sophisticated and precise, as diagnostic capabilities have expanded. Today, the field of precision medicine is emerging and has the potential to transform medicine by tailoring diagnostics, therapeutics, and prevention measures to individual patients.
- Advances in digital technology and telemedicine. Health and healthcare are being transformed by the development of digital technology with the potential to deliver information, link care processes, generate new evidence, and monitor health progress. Health information technology includes electronic health re- cords (EHRs), personal health records, e-prescribing, and m-health (mobile health) tools, including personal health tools, such as personal wellness devices and smartphone apps, and online peer support communities.
- Promise of “big data” to drive scientific progress. Large-scale data stores have the potential to reveal and further our understanding of subtle population patterns, heterogeneities and commonalities that are inaccessible in smaller data. Using big data, we can learn more about disease causes and outcomes, advance precision medicine by creating more precise drug targets, and better predict and prevent disease occurrence or onset.
Action plan
Four cross-cutting action priorities are clearly evident: pay for value, empower people, activate communities, and connect care.
- Pay for value – deliver better health and better results for all. Design and promote health financing strategies, policies, and payments that support the best results – the best value – for individuals and the populations of which they are a part.
- Empower people – democratize action for health. Ensure that people, including patients and their families, are fully informed, engaged, and empowered as partners in health and healthcare choices, and that care matches well with patient goals.
- Activate communities – collaborate to mobilize resources for health progress. Equip and empower communities to build and maintain conditions that support good health, link health and social services where possible, and identify and respond to health threats locally. A person’s ZIP code is perhaps the strongest predictor of health outcomes and life expectancy.
- Connect care – implement seamless digital interfaces for best care. Develop standards, specifications, regulatory policies and interfaces to ensure that patient care data and services are seamlessly and securely integrated, and that patient experience is captured in real time for continuous systemwide learning and improvement.
Source: Vital Directions for Health and Health Care: Priorities from a National Academy of Medicine Initiative, March 21, 2017, https://nam.edu/wp-content/uploads/2017/03/Vital-Directions-for-Health-Health-Care-Priorities-from-a-National-Academy-of-Medicine-Initiative.pdf?utm_source=National+Academy+of+Medicine&utm_campaign=b3e589f623-Vital+Directions+final+paper+announcement&utm_medium=email&utm_term=0_b8ba6f1aa1-b3e589f623-150926857