Two Years and Counting
Authors: Robert H. Brook
Journal: JAMA (2012)

IN LESS THAN 2 YEARS, ALL US CITIZENS AND LEGAL US RESIdents will have health insurance—except individuals who are willing to pay a penalty for not buying insurance. The United States is on the verge of joining the civilized world. Of course, this outcome will occur only if, among other things, the US Supreme Court does not rule that the Patient Protection and Affordable Care Act is unconstitutional, if US and state governments can enact the necessary policies and regulations, and if the health insurance exchanges required to implement the law will work. Whether a proponent or a critic of this law, most will agree with the undeniable fact that a new era in US medicine and US health care begins in less than 2 years. The key question is what potential measures should be monitored to determine both anticipated and unanticipated effects of the new law on the health of the US population. The first measure of the law’s success should be how much preventable mortality that is due to the health care system will be eliminated. Preventable mortality has many causes, ranging from personal behaviors to social determinants of health, to poor inpatient and outpatient care. Ways to assess preventable mortality have been available for many years. It is time to develop a national sampling frame of deaths and to determine, almost on a real-time basis, the proportion of an individual’s death that might have been prevented by better hospital care, better ambulatory care, or better personal behaviors. For example, a death from lung cancer in a patient who smoked could be attributed to smoking behavior, a stroke that occurred in a patient with inadequately controlled hypertension could be ascribed to poor ambulatory care, and an in-hospital death from a central line infection could be attributed to poor hospital care. The goal of health care reform should be to drive the number and proportion of preventable deaths that are under the control of the medical care system (ie, deaths due to poor ambulatory or hospital care) as close to zero as possible. National baseline data regarding the numbers of preventable deaths are necessary to monitor the change in the preventable death rate over time. The second measure of the law’s success should be how many preventable hospitalizations are avoided. The United States has a large number of avoidable hospitalizations from ambulatory-sensitive conditions. The rate of avoidable hospitalization varies across the nation by geographic area (poor neighborhoods have higher rates). Examining the reason that a patient was admitted to the hospital—eg, uncontrolled diabetes or asthma—can help to determine whether the hospital admission could have been avoided with better outpatient care. Thus, the second goal of health care reform should be to drive the avoidable hospitalization rate from ambulatory-sensitive conditions to zero. The third measure of the success of health care reform should be whether it increases to 100% the number of US residents who have access to a system of care. Loosely defined, this means that whether a patient needs emergency care, outpatient care, primary care, tertiary care, or an organ transplant, a coordinated system of care exists to ensure that the patient received the appropriate level of service and was able to access higher levels of medical care if needed. An organization that provides only emergency care without any arrangements for specific follow-up care does not represent a system of care. A health center that provides high-quality outpatient primary care but cannot arrange for subspecialty care or hospital care when needed is not a system of care. If a gynecologist needs to treat a woman with severe depression because she has no access to a mental health professional, she has no system of care. If the physician providing emergency care is not capable of reducing a complicated fracture but must attempt the reduction because no orthopedic surgeon is available, the patient with the fracture does not have a system of care. This loose definition of a system of care does not require that a patient have a primary care gatekeeper or restricted access to a specialist. Rather, it requires that patients have a reasonable chance of receiving the level of care they need in a reasonably timely manner. Systems of care range from an accountable care organization to a health maintenance organization to the Veterans Affairs, but systems must be sufficiently organized, so patients with serious problems are not left to fend for themselves. The fourth measure that can be used to monitor the health care reform act should be the cost of care divided by the num-