US and UK Healthcare Systems Should Learn From Each Other, Experts Conclude

In a health policy paper published on October 11, 2012 in The Lancet medical journal, US and UK experts on healthcare policy who co-authored the article conclude that, even though the US and UK healthcare systems are often thought of as polar opposites, “Policy makers and health-care managers in both countries should miss no opportunity to make progress by learning from one another, and from other international examples.”

The article, “Health-care reforms in the USA and England: areas for useful learning,” was co-authored by Dr Jennifer Dixon, Director of the Nuffield Trust in the UK, and Professor David Blumenthal of Harvard University in the USA. It was published in the online edition of The Lancet on October 11, 2012.

According to Dr Dixon, “Comparing health reforms in the USA and England seems to be an unlikely project: many people in both countries view the other as having a pariah health system that is not to be copied in any circumstance.” “But both countries are under pressure to get more value out of health care spending and reduce growth in expenditure to sustainable levels, and are consequently experimenting with new ways to encourage clinicians, patients, and institutions to help achieve this.”

Areas Where US and UK Healthcare Policymakers can Learn From Each Other

The authors analyze key features of the health care systems in the two countries. They focus on three key areas where healthcare policymakers and regulators in the two countries could learn valuable lessons from each other: (i) Financing and Financial Measures, (ii) Organizational Changes, and (iii) Information Management and Technology.

(i) Financing and Financial Measures

The authors point out that “In the USA, no binding overall budget is set prospectively for federal spending on Medicare and Medicaid— so-called entitlement programmes, in which individuals who meet specific eligibility criteria become entitled to care irrespective of its costs.” “Although governmental authorities try to estimate and control spending, they are bound by law to pay for whatever care eligible beneficiaries use.”

On the other hand, “In England, an upper limit of total expenditure for the NHS is agreed between the Department of Health and Her Majesty’s Treasury as part of 3-year spending reviews,” the authors state. This has meant, they say, that “When resources are scarce, the NHS [England's National Health Service] cuts services to patients (eg, limiting access to care through increased wait times or restricted adoption of new drugs, and allowing the quality of buildings, food, and cleanliness to decrease) and restricts staff compensation or training opportunities.”

“Effective central controls from policy makers on the total budget for the NHS have meant that understanding of the effect of specific policy decisions on expenditure has been less detailed in England; as the political pressures build, change will be necessary if spending is to be managed effectively,” the authors write.

They point out that a shortfall of £20 billion is predicted for the UK health care system by 2015, although the calculations behind this prediction remain largely “opaque and unchallenged”.

“The NHS could learn from the transparency and analytic rigour in the USA to model growth in costs,” they conclude. “An independent expert body similar to the Independent Payment Advisory Board proposed by the ACA [the U.S. Patient Protection and Affordable Care Act ("ACA"), which some call "Obamacare"], in the USA might be worth consideration” for the UK, they suggest.

The authors then mention different programs being implemented in each country with the common objective of “improving integration of services across settings.”

They also discuss different versions of payment reforms in provider compensation being tried in both countries — such as “value-based purchasing” in the UK, and “pay-for-performance” reforms as well as shared cost-savings through “accountable care organizations” under the U.S. Affordable Care Act, all with the objectives of controlling health care costs and tying costs to quality of service.

As to these programs, the authors conclude, “Overall, there is much potential for cross-national learning and assessment.”

(ii) Organizational Changes

In this area, the authors observe that “In view of England’s explicit control of the organisation of services and the coalition government’s desire to reduce NHS bureaucracy, the English reforms address structural elements of the health system much more directly than does the ACA in the USA.” They describe reforms underway under England’s “Health and Social Care Act, [which] is leading to the dismantling of several agencies and the adding or strengthening of several others.”

These organizational reforms in the UK include implementation of “clinical commissioning groups” which will empower groups of local providers to “switch contracts between acute and community providers,” thereby encouraging competition.

They highlight two organizational reforms made under the U.S. Patient Protection and Affordable Care Act: (1) implementation of an Independent Payment Advisory Board to “report to Congress and the President about ways to contain Medicare expenditures within limits set out in ACA legislation,” and (2) establishment of the Center for Medicare and Medicaid Innovation (part of CMS), funded with a budget of U.S. $10 billion for 10 years, to “identify, assess, and spread new models of care and payment innovation across Medicare and Medicaid programmes to improve quality and reduce cost.”

In this area, they suggest that perhaps the UK health system could learn from the U.S. — particularly with regard to the new Center for Medicare and Medicaid Innovation, which they approvingly describe.

They conclude that the UK’s NHS Commissioning Board, charged with implementing proposed reforms in England, finds the model of the U.S. Center for Medicare and Medicaid Innovation of “central interest.” The $10 billion budget of this new U.S. agency will “allow it to invest in initiatives that help to improve quality and lower costs,” they observe.

On the other hand, “In England, resources for service and payment innovation and assessment are fragmented,” the authors state. “In view of the pressing financial environment, co-ordinated investment in innovations to improve cost-effectiveness and rigorous, publicly reported assessment of their effects to maximise learning is urgently needed,” the authors conclude.

At “delivery level,” however, the authors observe that the U.S. is behind the UK, in its long-term emphasis on primary care. They site as an example that the U.S. Affordable Care Act includes a number of necessary measures to try to catch up with the UK in this area, by increasing the supply of primary-care physicians (by augmenting their Medicare and Medicaid fees and helping to pay their educational debt), as well as promoting “so-called patient-centered medical homes” (“sites where comprehensive primary-care services incorporate advanced health information technology and ancillary personnel”). “In England,” they point out, “medical homes already exist, partly through comprehensive general practice providing continuity of care for patients.”

However, they call for further reforms in the English medical homes, including “grouping of practices to offer more organised and multidisciplinary service, satisfactory out-of-hours cover, and care coordination across various providers.” In these areas, the authors conclude, “By contrast with the [U.S.] ACA, the set of reforms in England do nothing to directly address these issues.”

(iii) Information Management and Technology

In this area, the authors conclude that lessons learned from the UK’s rollout of universal electronic health care records could prove helpful in the US, which has struggled to create a system linking hospital inpatient and outpatient care records electronically.

“The UK is well ahead of the USA in the adoption of electronic health records in the primary-care sector, but has struggled to create a hospital system and to link inpatient and outpatient care electronically,” the authors observe.

They describe initiatives underway in the U.S. under the Affordable Care Act (ACA), as well as the HITECH Act (part of the U.S. economic stimulus law), to promote the adoption of electronic health records, establish national standards for electronic health information systems to “enable local exchange of information between diverse electronic health records,” and support “comparative effectiveness research” based on health care information and outcomes, while promoting the “sharing of information with patients” to “promote patients’ involvement in the management of their own health.”

The UK is engaged in reforms to their already well developed electronic health information system, with similar objectives, the authors point out.

“As the UK revises its own electronic health information strategy, and as the new US policy evolves, there will be great opportunities for cross-national learning about implementation of electronic health records,” the authors conclude.

Conclusions

In conclusion, the authors state that “The English and US health-care systems face the same imperative: to enable well-intentioned, well-trained professionals and health-care institutions to deliver, and their customers to consume, evidence-based services efficiently and effectively in the face of daunting resource constraints. Policy makers and health-care managers in both countries should miss no opportunity to make progress by learning from one another, and from other international examples.”

Pointing out the similarities in objectives for health care improvements in both countries, the authors conclude: “These similarities suggest that modern, developed health-care systems—no matter how seemingly diverse— have a specific set of ways in which to change the behaviour of providers and consumers and to motivate and direct such adjustments. Conscious and purposeful cross- national learning about experience with these interventions should be a priority for developed nations struggling with ageing populations, increasing demands for health services, and restricted resources.”

More Information

The new policy paper, “Health-care reforms in the USA and England: areas for useful learning,” is available in The Lancet medical journal, October 11, 2012 online edition.

For more news and information about the Patient Protection & Affordable Care Act, President Obama’s signature Health Care Law, and about health care reform in the U.S., as well as international comparisons of health care systems, see the HelpingYouCare^® resource pages on VoicesForCare™, including:

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