The U.S. has valuable lessons to teach other countries when it comes to establishing favorable economic incentives that support healthcare delivery. Despite being far from perfect, the tax system in the U.S. does facilitate the financial viability of healthcare services, especially provision of care to vulnerable populations. Per estimates of the United Nations, “if least developed countries raised at least 20 percent of their GDP, they would achieve all of the MDGs.”[i] Many of the Millennium Development Goals (MDG) entail health outcomes, such as reducing child mortality and improving maternal health, and an obvious means for a nation to raise its GDP would be by increasing tax rates among its citizens.
This solution is not as simple however for the developing nations that need this cash flow the most. Their economic incentives, such as tax-related incentives, are dictated by the investment decisions of wealthy individuals and multinational corporations that disproportionately reside in industrialized nations such as the U.S. Consequently, economic circumstances promoting poverty in the local population persist and many are ultimately motivated to migrate to wealthier nations. Unfortunately, immigrants do not similarly benefit from tax-related incentives in the U.S. and imperfect crowd-funding platforms, such as GoFundMe, are often utilized to meet the healthcare needs of poor migrants.[ii]
At the same time, the capacity of technology such as these crowd-funding platforms to address costs of care does have its merits. The Affordable Care Act has produced significant economic incentives for U.S. healthcare systems to “adopt and make meaningful use of health information technology systems”.[iii] Other counties would benefit from this framework of reducing costs of care and maximizing value through increased accessibility of information to both providers and consumers as well as centralization of data that can be mobilized to construct risk-stratification and other artificial intelligence tools.
Minimizing costs of care is intrinsically linked with approaching the care of noncommunicable diseases through the lens of preventative medicine. The U.S. in particular grapples with this dilemma. As medical advances are made, the populations becomes both older and more co-morbid. Thus, the U.S. can also learn from other countries, such as how to finance healthcare in a cost-effective and sustainable manner.
Specifically, there are some who think that the U.S. could work towards controlling costs through establishment of “fixed global budgets and predetermined fees for physicians” as is already being done in Canada.[iv] There is concern that creation of controlled capital budgets as a means of maximizing the public’s access to primary care can result in sacrifice of technologically advanced care. However, an increasing number of managed health plans in the United States are recognizing the merits of the system in Canada and are adopting similar health financing systems in provision of care without significantly undermining further medical advances.
Yet, advanced and costly technological care does not necessarily prolong quality of life and more Americans are becoming privy to the important distinction between extension of years of life and extension of meaningful living. Additionally, direct clinical experiences in developing countries can demonstrate to providers the feasibility of reducing “resource consumption of disposable resources at work”, “frequency/approach to ordering diagnostic lab studies and imaging studies” and “excessive use of and reliance on technology”.[v] It would behoove both insurers and providers in the U.S. to reconfigure the existing financing elements in healthcare delivery to have a greater focus on holistic care and health of entire communities.
Despite spending more on healthcare compared to other industrialized countries, the U.S. still has worse health outcomes such as maternal mortality rates. One reason for this could be the misalignment in resources prioritized towards specialty care versus primary care. On review of healthcare proposals by both industrialized and developing nations, clear themes of
population health management, multidisciplinary ambulatory care, and mental health care emerge.[vi]
Patient engagement continues to suffer in the United States as health inequities in access to care persist. While there is typically an oversupply of specialty care in urban settings, many parts of the U.S. continue to have hospitals without a single emergency physician. This inevitably leads to disparities in care delivery and outcomes.
Both industrialized and developing nations specifically address the issue of rural health disparities. Venezuela’s and Pakistan’s plans, for instance, target expansion of technology into rural areas.[vii] Germany also focuses on technology, particularly with respect to broadening telemedicine, but their plan also explores design of evidence-based solutions for addressing inefficiencies in healthcare delivery in rural settings through support of larger-scale research projects.[viii]
Ultimately, while the U.S. excels in health innovation and technological revolution, it can certainly benefit from adopting elements of business models used by other countries to address systemic issues with how we address care. As already mentioned, the U.S. spends more than other countries but has worse health outcomes. One reason for this is that the U.S. inadequately addresses structural determinants of health inequity such as housing instability and food insecurity.
Countries such as Yemen have radically reimagined the scope of healthcare delivery. In particular, they are moving away from hospital-based care to community and population-based healthcare. Although Yemen is presumably incentivized towards this shift as a resource-limited country, the U.S. is certainly not devoid of areas with resource limitations, such as rural counties, that would greatly benefit from this model. In many ways, the COVID-19 pandemic accelerated the drive to radically reconfigure the scope of healthcare delivery in the U.S. Telemedicine is more pervasive and now made financially viable through insurers who recognize its positive impact on patient satisfaction and cost reduction.
The emergency department is often the attention of costly care as it is conventionally designed to address high-risk, low frequency medical conditions. During the pandemic, patient volumes dropped across the country as patients rightfully so avoided going to the hospital if possible. In response, many EDs, including my own, launched or expanded existing telemedicine services and these services are now even more important as patient volumes have returned but the pandemic remains.
Moving forward, as the U.S. population continues to grow older and more co-morbid with hospital space not expected to increase at a similar rate, the ED will need to evolve to become the frontlines of both emergency and unpredictable care. Instead of having to rely on the business hours held by primary care physicians, the ED can champion community and population-based care such as through increased provision of home health care services and development of community para-medicine. There is great potential value in lessons learned from neighboring countries to continuously improve the health and well-being of Americans in the future.
[i] Creating Global Health
[ii] Creating Global Health
[iii] International Health System Reforms
[iv] International Health System Reforms
[v] Globalization and Health
[vi] Background of Initiatives and Enhancement Projects In‐Country
[vii] Background of Initiatives and Enhancement Projects In‐Country
[viii] Background of Initiatives and Enhancement Projects In‐Country