by Allison VanLue
Most in the industry agree the U.S. healthcare system is the black sheep of healthcare systems among rich, industrialized nations when it comes to providing high-quality care at a reasonable cost. Among developed countries, we are the only country that does not provide basic care to all individuals, the country that pays the most for our healthcare, and the country that has the worst outcomes. In his book, The Healing of America: A Global Quest of Better, Cheaper, and Fairer Healthcare, T.R. Reid states, “each nation’s health care system is a reflection of its history, politics, economy, and national values.” Being cognizant of the history that has gone into the U.S. healthcare system and the political, economic, and national values that keep the healthcare system what it is today, I do not plan to argue that the U.S. should switch over to any other country’s system, no matter how well it may work for them. Instead, after spending 6 years working in healthcare IT in Australia, the Middle East, and Europe, I’d like to share some observations from hospital systems I worked with in hopes that the U.S. can learn a few lessons to enhance access to care, reduce costs, and improve patient outcomes.
It is possible to have a complex, multifaceted healthcare system but still provide basic coverage to all citizens. Australia is a good example of this. I spent two years in Australia implementing an electronic health record (EHR) in the outpatient clinics of a tertiary care hospital which worked in both the public and private sector. When helping design their billing workflows, we reviewed the reimbursement models with the physicians. I found out that the same physician, in the same clinic, can be publicly funded for some visits and privately funded for other visits. If the visit was publicly funded, we captured visit statistics to get funding from the state government based on volume. If the visit was privately billed, fee-for-service charges were sent to the patient’s private insurance, and the configuration we did in the EHR supported both. This explanation is a bit oversimplified but as I started to investigate more, I realized the U.S. healthcare system is not the only one that has a complex patchwork of public and private financing.
The similarities between the U.S. and Australian healthcare do not stop there. The Australian federal government has a limited role in direct service delivery, in which it mostly provides funding to the states and subsidizes national programs – just like in the United States. The two big differences between U.S. and Australian healthcare: Australia spends much less on healthcare (about 9% versus 17% of GDP) and Australia provides basic care to all citizens. In the U.S., we leave about 30 million citizens uninsured, needing to pay for medical services out-of-pocket, ending with them either choosing not to receive care or to run the risk going bankrupt.
Specialty departments in U.S. hospital systems often function as silos, wasting resources and causing higher costs. Switzerland had a healthcare system much like the American system prior to its reform in 1994 in which for-profit insurance companies drove up costs and denied access to care to those most in need. After the reform, all citizens are required to pay a premium to insurance companies for basic coverage, and the insurance companies were not allowed to make a profit on basic coverage. Although the Swiss are pleased with their current system, one side-effect was smaller profit margins for the hospitals motivating the hospitals to get creative with reducing costs.
One way they reduced costs was in the form of a ‘Day Treatment’ (Tagesklinik in German) center in which multiple specialties share expensive resources such as highly-trained nurses and modalities. I worked with a Swiss hospital to implement an EHR in the day treatment areas which proved to be quite difficult due to the vast array of different departments who utilized the treatment center and the number of procedures they covered. Despite our daily EHR implementation struggles, the cost-sharing mechanism of this center had me mesmerized. This center did infusions for Oncology, Rheumatology, Neurology, Nephrology, and more. They did ECGs and lab draws for the majority of the hospital. They functioned as a step-down unit for outpatient procedures so specialties such as Gastroenterology and Pulmonology could increase their procedure room utilization. The U.S. could take a lesson from the Swiss – and most of Europe where these types of centers are commonplace – to reduce costs for expensive equipment in each specialty department and increase resource sharing for highly trained nurses. We are starting to see centers like this in healthcare organizations who need to be lean such as safety-net hospitals, but as all hospitals are starting to look for ways to remain financially solvent after COVID-19, finding ways to share resources in an efficient way would be a good strategy to look into.
Nationalized healthcare incentivizes health systems to have a higher focus on preventative medicine and the promotion of healthy lifestyles. Finland provides universal healthcare to its citizens through what Americans would call ‘socialized medicine’, which is also known as paying taxes so your healthcare is free or subsidized. Although universal healthcare through taxation is a scary concept to a lot of Americans, it is an excellent incentive for countries to focus on preventative care and social services. The healthier your citizens are the less the government has to pay down the road for expensive medical treatments. In the U.S., insurance companies have little incentive to cover preventative care or social services. By the time preventative care cost savings are realized, the patient will not be with the same insurance plan thus making offering preventative services bad for the bottom line.
In contrast to the U.S. system, Finland’s main health initiatives for the last decade have revolved around the prevention of diseases and promoting healthy lifestyles. When our American EHR company entered the Finish market, one of the primary objectives was functionality to support their social care sector. Social care in Finland refers to social services that meet the needs of the most vulnerable populations such as addiction or mental health services. Since social care often lies outside the U.S. healthcare realm, this was not something the software currently provided. A team of developers and project managers works with to design social care software that integrated seamlessly into the medical software. This includes enrolling patients in social services, clinical documentation, and outcome tracking. By having an integrated health and social software system, Finland care providers were able to focus on outcome tracking for their highest risk populations. The U.S. is headed in the right direction by starting to focus on positive patient outcomes with value-based care models. However, until we introduce a health system that discourages insurance companies from making a profit on basic coverage, the larger focus will stay on medical treatment rather than health promotion.
Americans are proud people – it has been ingrained in us since birth that we are the best country in the world. However, when it comes to healthcare, we are (statistically) not the best. There are 36 other countries who provide better healthcare than the United States of America, and if we study their history, politics, economics, and national values, surely, we can find a way to provide basic coverage to all citizens, reduce healthcare costs, and keep citizens healthier for longer.
