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Toward a 21st-Century Health Care System: Recommendations for Health Care Reform
- Kenneth Arrow, PhD;
- Alan Auerbach, PhD;
- John Bertko, BS;
- Shannon Brownlee, MS;
- Lawrence P. Casalino, MD, PhD;
- Jim Cooper, JD;
- Francis J. Crosson, MD;
- Alain Enthoven, PhD;
- Elizabeth Falcone;
- Robert C. Feldman, MD;
- Victor R. Fuchs, PhD;
- Alan M. Garber, MD, PhD;
- Marthe R. Gold, MD, MPH;
- Dana Goldman, PhD;
- Gillian K. Hadfield, JD;
- Mark A. Hall, JD;
- Ralph I. Horwitz, MD;
- Michael Hooven, MS;
- Peter D. Jacobson, JD, MPH;
- Timothy Stoltzfus Jost, JD;
- Lawrence J. Kotlikoff, PhD;
- Jonathan Levin, PhD;
- Sharon Levine, MD;
- Richard Levy, PhD;
- Karen Linscott, MA;
- Harold S. Luft, PhD;
- Robert Mashal, MD;
- Daniel McFadden, PhD;
- David Mechanic, PhD;
- David Meltzer, MD, PhD;
- Joseph P. Newhouse, PhD;
- Roger G. Noll, PhD;
- Jan B. Pietzsch, PhD;
- Philip Pizzo, MD;
- Robert D. Reischauer, PhD;
- Sara Rosenbaum, JD;
- William Sage, MD, JD;
- Leonard D. Schaeffer;
- Edward Sheen, MD, MBA;
- B. Michael Silber, PhD;
- Jonathan Skinner, PhD;
- Stephen M. Shortell, PhD, MPH;
- Samuel O. Thier, MD;
- Sean Tunis, MD;
- Lucien Wulsin, Jr., JD;
- Paul Yock, MD;
- Gabi Bin Nun, MA;
- Stirling Bryan, PhD;
- Osnat Luxenburg, MD; and
- Wynand P.M.M. van de Ven, PhD
- From Stanford University, Stanford; University of California, Berkeley, Los Angeles, and San Francisco; University of Southern California, Los Angeles; The Permanente Medical Group, Oakland; Hill Physicians Medical Group, San Ramon; Varian Medical Systems and Palo Alto Medical Foundation Research Institute, Palo Alto; and Insure the Uninsured Project, Santa Monica, California; University of Michigan, Ann Arbor, Michigan; University of Chicago, Chicago, Illinois; Humana, Louisville, Kentucky; Enable Medical Technologies, Cincinnati, Ohio; University of Texas at Austin, Austin, Texas; Wake Forest University, Winston-Salem, North Carolina; Washington and Lee University, Lexington, Virginia; New America Foundation, The Leapfrog Group, The Urban Institute, George Washington University, and the U.S. House of Representatives, Washington, DC; Center for Medical Technology Policy, Baltimore, Maryland; Rutgers University, New Brunswick, New Jersey; Weill Cornell Medical College, Ithaca, and City University of New York, New York, New York; Boston University, NKT Therapeutics, and Harvard University, Boston, Massachusetts; Dartmouth School of Medicine, Hanover, and Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire; Ben Gurion University, Beer Sheva, Ministry of Health, Jerusalem, Israel; University of Birmingham, Edgbaston, Birmingham, United Kingdom; and Erasmus University, Rotterdam, the Netherlands.
Abstract
The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform:
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Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment.
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Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions.
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Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions.
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Develop a health information technology infrastructure with national standards of interoperability to promote data exchange.
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Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers.
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Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans.
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Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage.
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Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.
Article and Author Information
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Disclaimer: The views presented in this work represent the views of the authors and not the views of their employers or of the U.S. government.
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Acknowledgment: The authors thank Dr. Ezekiel Emanuel for his leadership in organizing the FRESH-Thinking workshops and helping to prepare initial drafts of the manuscript and Emily Tashman for her administrative support.
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Potential Financial Conflicts of Interest: Employment: F.J. Crosson (Kaiser Permanente); R. Mashal (NKT Therapeutics); L. Wulsin Jr. (Director, Insure the Uninsured Project). Consultancies: J.P. Newhouse (Director, Aetna); L. Schaeffer (consultant to private equity firm). Stock ownership or options: R. Mashal (equity ownership, public and private biotechnology companies); D. Mechanic (McKesson Corporation); J.P. Newhouse (equity ownership, Aetna); L. Schaeffer (Pharmaceutical companies and outpatient surgery centers); S.O. Thier (Director, Charles River Laboratories; Director, Merck & Co.). Grants received: D. Mechanic (Robert Wood Johnson Foundation); L. Wulsin Jr. (The California Endowment, The California Wellness Foundation, L.A. Care Health Plan, Blue Shield of California Foundation). Royalties: D. Mechanic (The Truth about Health Care: Why Reform is Not Working in America. Piscataway, NJ: Rutgers Univ Pr; 2006.) Other: J.P. Newhouse (Director of NCQA [unpaid]).
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Requests for Single Reprints: Stephen M. Shortell, PhD, MPH, School of Public Health, University of California, Berkeley, 50 University Hall, Berkeley, CA 94720.
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Current Author Addresses: Drs. Arrow, Fuchs, Levin, and Noll: Department of Economics, Stanford University, Landau Economics Building, 579 Serra Mall, Stanford, CA 94305-6072.
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Dr. Auerbach: Department of Economics and School of Law, University of California, Berkeley, 549 Evans Hall #3880, Berkeley, CA 94720-3880.
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Mr. Bertko: 1084 East Sterling Lane, Flagstaff, AZ 86001.
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Ms. Brownlee: New America Foundation, 1899 L Street NW, Suite 400, Washington, DC 20036.
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Dr. Casalino: Department of Public Health, Weill Cornell Medical College, 402 East 67th Street, New York, NY 10021.
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Mr. Cooper: U.S. Congressman, Tennessee 5th District, U.S. House of Representatives, 1536 Longworth House Office Building, Washington, DC 20515.
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Dr. Crosson: Kaiser Permanente Institute for Health Policy, 1950 Franklin Street, 20th Floor, Oakland, CA 94612.
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Dr. Enthoven: Graduate School of Business, Stanford University, 518 Memorial Way, Stanford, CA 94305-5015.
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Ms. Falcone: U.S. Congress, 1536 Longworth House Office Building, Washington, DC 20515.
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Dr. Feldman: Hill Physicians Medical Group, 868 Paramount Road, Oakland, CA 94610-2437.
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Dr. Garber: Department of Veterans Affairs Palo Alto Care System and Center for Health Policy, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.
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Dr. Gold: City College, City University of New York, 138th Street and Convent Avenue, Room J 920, New York, NY 10031.
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Dr. Goldman: David Geffen School of Medicine and School of Public Health, University of California, Los Angeles, PO Box 951772, Los Angeles, CA 90095.
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Ms. Hadfield: Law Center and Department of Economics, University of Southern California, 699 Exposition Boulelvard, Los Angeles, CA 90089-0071.
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Mr. Hall: Schools of Law and Medicine, Wake Forest University, Worrell Professional Center, PO Box 7206, Reynolds Station, Winston-Salem, NC 27109.
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Dr. Horwitz: Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room S102, MC 5110, Stanford, CA 94305.
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Mr. Hooven: Enable Medical Technologies, 7778 Bennington Drive, Cincinnati, OH 45241.
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Mr. Jacobson: School of Public Health, University of Michigan, 109 Observatory Street, Ann Arbor, MI 48109.
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Mr. Jost: School of Law, Washington and Lee University, 4008 Sydney Lewis Hall, Lexington, VA 24450.
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Dr. Kotlikoff: Department of Economics, Boston University, 270 Bay State Road, Boston, MA 02215.
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Dr. Levine: The Permanente Medical Group, 1950 Franklin Street, 20th Floor, Oakland, CA 94612.
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Dr. Levy: Varian Medical Systems, 3100 Hansen Way, M/S E-220, Palo Alto, CA 94304.
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Ms. Linscott: The Leapfrog Group, 1150 17th Street Northwest, Suite 600, Washington, DC 20036.
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Dr. Luft: Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA 94301.
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Dr. Mashal: Alinea Pharmaceuticals, 1 Memorial Drive, Suite 1225, Cambridge, MA 02142.
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Dr. McFadden: Department of Economics, University of California, Berkeley, 508-1 Evans Hall #3880, Berkeley, CA 94720-3880.
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Dr. Mechanic: Institute of Health, Health Care Policy and Aging Research, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901.
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Dr. Meltzer: Departments of Medicine and Economics and School of Public Policy, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.
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Dr. Newhouse: Schools of Medicine, Public Health, Government, and Arts and Sciences, Harvard University, 180 Longwood Avenue, Boston, MA 02115.
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Dr. Pietzsch: Department of Management Science and Engineering, Stanford University, Terman Engineering Center, 3rd Floor, 380 Panama Way, Stanford, CA 94305-4026.
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Dr. Pizzo: School of Medicine, Stanford University, 300 Pasteur Drive, Room M-121, Stanford, CA 94305-5119.
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Dr. Reischauer: The Urban Institute, 2100 M Street NW, Washington, DC 20037.
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Ms. Rosenbaum: School of Public Health, George Washington University, 2021 K Street NW, Suite 800, Washington, DC 20006.
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Dr. Sage: School of Law, University of Texas at Austin, 727 East Dean Keeton Street, Austin, TX 78705.
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Mr. Schaeffer: University of Southern California, Lewis Hall 312, Los Angeles, CA 90089-0626.
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Dr. Sheen: School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA 02115.
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Dr. Silber: Department of Neurology, School of Medicine, University of California, San Francisco, 513 Parnassus Avenue, San Francisco, CA 94143.
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Dr. Skinner: Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth School of Medicine, 6106 Rockefeller Hall Dartmouth College, Hanover, NH 03755-3514.
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Dr. Shortell: School of Public Health, University of California, Berkeley, 50 University Hall, Berkeley, CA 94720.
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Dr. Thier: Departments of Medicine and Health Policy, Harvard Medical School, 55 Fruit Street, Boston MA 02114.
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Dr. Tunis: Center for Medical Technology Policy, 4712 Keswick Road, Baltimore, MD 21210.
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Mr. Wulsin: Insure the Uninsured Project, 2444 Wilshire Boulevard, Suite 415, Santa Monica, CA 90403.
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Dr. Yock: Department of Bioengineering, Stanford University, 318 Campus Drive, Room E100, Stanford, CA 94305-5428.
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Mr. Bin Nun: Department of Health System Management, Ben Gurion University of the Negev, PO Box 653, Beer Sheva 84105, Israel.
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Dr. Bryan: Department of Health Economics, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.
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Dr. Luxenburg: Ministry of Health, Israel, 2 Ben Tabai Sreet, Jerusalem, Israel 93591.
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Dr. van de Ven: Erasmus University, PO Box 1738, 3000 DR Rotterdam, the Netherlands.
