Limits to the predictive value of trends in European health reform.

Bradford L. Kirkman-Liff's article provides the reader with unique insights into the health care reforms of selected European countries and contrasts these reforms with what is taking place in the United States. Kirkman-Liff's analysis is comprehensive and based on an enviable amount of experience. The United States health care manager will find the international context of these observations both enlightening and refreshing given a time in the United States of enormous analysis, debate, and stress within our current system. The premise of the article is intriguing--that is, countries with forms of state-controlled or public health care including universal coverage and access are, in fact, converging by way of their response to problems in their systems. The ultimate questions created by the premise are, however, whether or not this convergence is predictive and whether that prediction can be beneficial to the United States health care manager and/or policymaker. Without some analysis, the reader might be tempted to interpret the oft-used and pivotal term "convergence" as two health care systems moving in similar directions on a converging course and, hence, becoming more alike. In fact, convergence can mean difference things. On one hand, convergence can be health care systems moving in totally opposite directions from extreme points on a continuum yet moving toward each other. For example, health care systems that are heavily socialized might be moving toward market-driven principles. On the other hand, systems of almost complete competition may be moving toward greater socialization. Kirkman-Liff's research points out two examples. One, a move on the part of health care systems in Europe to the use of co-pays and deductibles as a way of controlling patient utilization and access, whereas much of the current debate in this country is on removing cost-associated barriers to improve access. Another example would be a common direction amongst the European health care systems cited to increase physician incentives, whereas, in this country, there is serious concern about physicians being overincentivized, which leads to abuse within the system. In these examples, systems are moving in opposite directions toward each other. Convergence can also mean health care systems moving in the same direction on a converging track. The article points to several trends in the United Kingdom, the Netherlands, and Germany of moving toward a more market-driven health care system. Although each of these three health care systems, which would be on the other end of the spectrum from the United States, would be using a different approach to implement market forces, it will be likely that a common movement toward market principles amongst the European systems cited will lead to a convergence. As a sidebar, the applicability of these observations of convergence seem to have limited value when specific recommendations are made by Kirkman-Liff, but seem to have more logic and intuition when they relate to some of the highest conceptual issues such as universal coverage, enhanced access to primary care providers, and the increased involvement with the federal government in managing the health care system. As Kirkman-Liff reviews the six major areas of analysis within his article, there are several "direct hits" on comparability with issues that are facing U.S. policymakers and managers. These include: (1) the observation that virtually all health care reform today is driven by cost, (2) the fact that all countries face cost implications of an aging population, (3) the fact that all systems will benefit from some degree of competition and accountabilities, and (4) an intriguing observation that the availability of private components in a health care system puts pressures on the public component to perform. There are, however, several "misses" in the observations as well. They include: any suggestion of a potential that HIV infection and AIDS care will overwhelm or swamp the U. …