America’s healthcare system is in dire need of reform. The U.S. spends more on healthcare than any other high-income country, yet has worse outcomes and lower satisfaction. Millions of Americans lack access to affordable and quality care, and face the risk of financial ruin if they get sick. Healthcare disparities, waste, inefficiency, and bureaucracy plague the system and prevent it from delivering on its promise of improving health and well-being. How can we fix this broken system? There is no easy or simple answer, but there are some common-sense solutions that could make a difference.
Here are five possible fixes for America’s healthcare system, based on evidence and best practices from other countries and sectors:
1. Reimburse telehealth visits at the same rate as in-person care. Telehealth, or the use of technology to deliver healthcare services remotely, has been a lifeline for many Americans during the COVID-19 pandemic. Telehealth can improve access, convenience, quality, and cost-effectiveness of care, especially for people who live in rural areas, have mobility issues, or face other barriers to in-person care. Telehealth can also reduce the burden on hospitals and clinics, and prevent the spread of infections. However, telehealth is not reimbursed at the same rate as in-person care by most public and private payers, which creates a disincentive for providers to offer it. This is unfair and illogical, as telehealth can provide the same or better outcomes as in-person care for many conditions and services. The U.S. government should mandate parity for telehealth reimbursement, and encourage states and insurers to follow suit.
2. Institute a virtual-first approach for primary and chronic care. Primary and chronic care are the cornerstones of a well-functioning healthcare system. They can prevent or manage many common and costly diseases, such as diabetes, hypertension, asthma, and depression. They can also improve patient satisfaction, adherence, and quality of life. However, primary and chronic care are often underutilized, fragmented, and inefficient in the U.S.. Many Americans do not have a regular source of primary care, or face long wait times, high copays, and limited availability of appointments. Many Americans with chronic conditions do not receive adequate or timely care, or face gaps in coordination and communication among their providers. A ‘virtual-first approach’ for primary and chronic care could address these challenges. A virtual-first approach means that patients are assigned to a primary care provider who delivers most of their care through telehealth platforms, such as phone calls, video visits, messaging, or apps. Patients can still access in-person care when needed, but the default option is virtual. This way, patients can receive more convenient, continuous, comprehensive, and personalized care from their primary care provider, who can also coordinate their referrals, prescriptions, tests, and follow-ups. A virtual-first approach for primary and chronic care has been shown to improve outcomes, reduce costs, and increase satisfaction for patients and providers alike. For example, a study by Harvard Medical School found that a virtual-first primary care model led by nurse practitioners resulted in 33% lower spending, 80% fewer emergency department visits, and 40% fewer hospitalizations than traditional primary care.
3. Establish parity for mental and physical health. Mental health is an integral part of overall health, yet it is often neglected or stigmatized in the U.S. healthcare system. Mental health conditions affect one in five Americans each year, and are associated with higher rates of morbidity, mortality, and disability. Mental health conditions also impose a huge economic burden on society, costing an estimated $210 billion per year in lost productivity, and $193 billion per year in direct healthcare spending. Despite the prevalence and impact of mental health conditions, many Americans do not receive adequate or appropriate care for them. According to a report by Mental Health America, 60% of adults with a mental illness did not receive any treatment in the past year, and 56% of youth with a major depressive episode did not receive any treatment in the past year. One of the main reasons for this gap is the lack of parity between mental and physical health in terms of coverage, reimbursement, access, and quality. The U.S. government should enforce parity for mental and physical health, meaning that mental health services should be covered at the same level as physical health services by all public and private payers, and that mental health providers should be reimbursed at the same rate as physical health providers. The U.S. government should also invest more in expanding access to mental health services, especially for underserved populations, such as rural residents, minorities, veterans, and children, as well as promote quality improvement and innovation in mental health services, such as integrating mental health into primary care, using telehealth and digital tools, and implementing evidence-based practices.
4. Provide universal mental health screening. One of the challenges of addressing mental health in the U.S. is the lack of early detection and intervention. Many people with mental health conditions do not seek help until their symptoms become severe or interfere with their daily functioning. This can lead to worse outcomes, higher costs, and greater suffering. Universal mental health screening could help identify and treat mental health conditions before they escalate or become chronic. Universal mental health screening means that everyone, regardless of age, gender, race, or risk factors, is offered a brief and validated questionnaire to assess their mental health status at regular intervals, such as during annual physical exams, school check-ups, or workplace wellness programs. Those who screen positive for a mental health condition are then referred to appropriate services for further evaluation and treatment. Universal mental health screening has been recommended by several professional and advocacy organizations, such as the American Academy of Pediatrics, the American Psychological Association, and Mental Health America. Universal mental health screening has been shown to be feasible, acceptable, and effective in various settings, such as primary care, schools, and workplaces. For example, a study by the University of Michigan found that universal depression screening in primary care increased the detection of depression by 33%, and improved the quality of care and outcomes for depressed patients.
5. Shift pricing to a value-based model. One of the root causes of the high cost and low quality of healthcare in the U.S. is the fee-for-service model, which pays providers based on the volume and complexity of services they deliver, regardless of the outcomes or value they produce. This creates perverse incentives for providers to overuse or misuse tests, procedures, drugs, and other services that may not benefit patients or may even harm them. It also discourages providers from investing in prevention, coordination, and innovation that could improve health and reduce costs in the long run. A value-based model, on the other hand, pays providers based on the outcomes and value they deliver for patients and populations, such as improving health status, reducing complications, enhancing satisfaction, and lowering costs. This aligns the incentives of providers with the goals of patients and payers, and encourages providers to deliver high-quality, low-cost, and patient-centered care. A value-based model can take various forms, such as bundled payments, shared savings, pay-for-performance, or capitation. The U.S. government should accelerate the transition from fee-for-service to value-based models by expanding and improving existing programs, such as the Medicare Shared Savings Program, the Bundled Payments for Care Improvement Initiative, and the Comprehensive Primary Care Plus Model. The U.S. government should also support and incentivize private payers and employers to adopt value-based models and collaborate with providers and consumers to achieve better health outcomes and lower costs for all.
America’s healthcare system is broken, but it can be fixed. The five possible fixes presented here are not exhaustive or mutually exclusive, but they are based on evidence and best practices from other countries and sectors. They are also bipartisan and pragmatic, meaning that they can garner support from both sides of the political aisle and from various stakeholders in the healthcare system. By implementing these fixes, we can create a healthcare system that works for everyone and fulfills its promise of improving health and well-being.