The health care system is an enormous, complex, and highly regulated industry that produces services with a wide range of prices and quality. Its delivery involves a wide variety of technical, interpersonal, manual, cognitive and organizational skills. It is a sector that has been the focus of significant concerns about professionalism, regulation, malpractice, and the allocation of resources. In addition, its outcomes vary widely among individuals. The good news is that people are generally satisfied with their medical care and the health care providers they deal with. The bad news is that a considerable burden of harm results from deficiencies in the health care delivery system. These deficiencies are associated with inappropriate utilization of the health care services and selective ineffective utilization, as well as poor clinical judgment.
A large body of research has documented specific areas of health care quality problems — some of which can be attributed to poor technical proficiency and judgment, some to overuse of unnecessary or inappropriate services, and some to inadequate access. There are also problems resulting from the use of unproven or experimental procedures and therapies, as well as problems arising from the failure to follow treatment guidelines.
From a positive perspective, the quality of health care can be enhanced by a variety of public and private actions. These include instilling a professional culture that emphasizes agency, socializing health care providers (or, in economic jargon, modifying their incentive structures) to act differently than the prototypical supplier of a market good who acts in his or her own self-interest, and instituting regulatory initiatives that promote cost-effectiveness, such as prospective payment systems and capitated programs.
Another important policy objective is to systematically incorporate cost effectiveness into coverage decisions, thereby promoting innovation in new technologies. A number of countries, including Switzerland and the United Kingdom, are cited as examples of high-performing systems that do so.
A third objective is to improve access to health care services, which focuses on the availability and affordability of health services at the population level. The Netherlands, Australia, and the United States are clustered closely together as top-performing systems in this dimension. The United States is far behind, however, in the two other dimensions of accessibility and quality of services.
The United States is also a leader in the area of medical technology and has produced many advances in life-saving treatments. The challenge is to find ways to better manage the increasing costs of such innovations so that they do not crowd out other investments in the nation’s future.
An essential aspect of this is ensuring that all parties have access to meaningful information about health care. A focus on decision making facilitates this goal by enabling individuals to choose appropriate and effective services. Informed decision making also requires that accountability be based on evidence rather than simply on outcomes; this is an especially difficult task when multiple stakeholders are involved. Accountability should be tied to a commitment to value purchasing.