Jane M. Anderson

Each day in the United States, roughly one doctor dies by suicide. Studies over the past 4 decades have confirmed that physicians—especially women physicians—die by suicide more frequently than people in other professions or those in the general population.

“Physicians have the means and the knowledge and access to ways to kill themselves,” Dr. Paula Clayton, a psychiatrist and medical director for the American Foundation for Suicide Prevention, said in an interview.

But the data on physicians dying by suicide are difficult to come by, and “we certainly don't have any data that [say] any particular specialty has any higher rates of suicide,” she said.

Although no information is available on the risk of suicide by specialty, researchers do know that physician suicides are equally divided between men and women, whereas in the general population, four times as many men kill themselves as do women, according to Dr. Clayton.

Awareness of the problem remains low, and professional and cultural barriers deter or prevent physicians who are depressed from seeking treatment for their illness, Dr. Clayton said. For example, most physicians do not have a regular source of health care; only 35% of doctors have a personal physician, and even fewer interns and residents have a doctor themselves.

Dr. W. Gerald Austen, surgeon-in-chief emeritus at Massachusetts General Hospital, has first-hand experience. Twenty-eight years ago, when he was surgeon-in-chief, one of his younger staff committed suicide. And about 11 years ago, a surgical resident committed suicide.

Those deaths were the saddest moments of his career, yet Dr. Austen said he doesn't know what could have been done to prevent these young physicians from taking their own lives.

“It wasn't as if the institution and the department weren't aware that they had some problems,” he said in an interview. “Both of these individuals were under psychiatric care. They were believed by both their doctors and their contemporaries and colleagues to be doing rather well.”

In each case, the surgery department reviewed the situation with the psychiatry department, Dr. Austen said, and “we certainly did everything we could in terms of their family in both cases.” But he said the department didn't find any procedures to change internally as a result of the deaths.

It's possible that increasing awareness of physician depression could help get physicians the help they need before it's too late, Dr. Austen said. “Friends who work with people in medicine need to be aware that, if they see something that concerns them, they need to transmit the message to the powers that be.”

But it's difficult to know the difference between someone who is simply unhappy, and someone who is clinically depressed and potentially at risk for suicide, he added. “[Physicians believe] their job is to help other people with problems. If they have a problem themselves, they would prefer to not have people know about it,” said Dr. Austen.

“There's this proudness about their ability to cope,” Dr. Clayton said. “They are reluctant to seek help because they fear the stigma will harm them—people won't refer them patients, the hospital might revoke their privileges, and licensing could become a problem.”

State medical licensing boards ask for information on whether the person applying for licensure has been treated for a mental illness, and that information can affect licensing, she said. “I worked with a physician who took lithium,” she said. “The state board made him get blood drawn periodically to prove he continued to take it. That's punitive—they don't do that for other illnesses.”

However, some progress has been made: A total of 19 states now focus specifically on whether an applicant is impaired because of psychiatric illness, she said.

Dr. Clayton's group recently funded the production of three films on physician suicide as part of an ongoing outreach campaign that seeks to educate physicians about depression. One of the films was designed specifically as an educational video for use at medical schools. Because many of the mood disorders that can lead to suicide might become evident first during medical school, where professional and institutional barriers already exist, the goal of that program is to encourage medical students to seek help for depression.

Each day in the United States, roughly one doctor dies by suicide. Studies over the past 4 decades have confirmed that physicians—especially women physicians—die by suicide more frequently than people in other professions or those in the general population.

“Physicians have the means and the knowledge and access to ways to kill themselves,” Dr. Paula Clayton, a psychiatrist and medical director for the American Foundation for Suicide Prevention, said in an interview.

But the data on physicians dying by suicide are difficult to come by, and “we certainly don't have any data that [say] any particular specialty has any higher rates of suicide,” she said.

Although no information is available on the risk of suicide by specialty, researchers do know that physician suicides are equally divided between men and women, whereas in the general population, four times as many men kill themselves as do women, according to Dr. Clayton.

Awareness of the problem remains low, and professional and cultural barriers deter or prevent physicians who are depressed from seeking treatment for their illness, Dr. Clayton said. For example, most physicians do not have a regular source of health care; only 35% of doctors have a personal physician, and even fewer interns and residents have a doctor themselves.

Dr. W. Gerald Austen, surgeon-in-chief emeritus at Massachusetts General Hospital, has first-hand experience. Twenty-eight years ago, when he was surgeon-in-chief, one of his younger staff committed suicide. And about 11 years ago, a surgical resident committed suicide.

Those deaths were the saddest moments of his career, yet Dr. Austen said he doesn't know what could have been done to prevent these young physicians from taking their own lives.

“It wasn't as if the institution and the department weren't aware that they had some problems,” he said in an interview. “Both of these individuals were under psychiatric care. They were believed by both their doctors and their contemporaries and colleagues to be doing rather well.”

In each case, the surgery department reviewed the situation with the psychiatry department, Dr. Austen said, and “we certainly did everything we could in terms of their family in both cases.” But he said the department didn't find any procedures to change internally as a result of the deaths.

It's possible that increasing awareness of physician depression could help get physicians the help they need before it's too late, Dr. Austen said. “Friends who work with people in medicine need to be aware that, if they see something that concerns them, they need to transmit the message to the powers that be.”

But it's difficult to know the difference between someone who is simply unhappy, and someone who is clinically depressed and potentially at risk for suicide, he added. “[Physicians believe] their job is to help other people with problems. If they have a problem themselves, they would prefer to not have people know about it,” said Dr. Austen.

“There's this proudness about their ability to cope,” Dr. Clayton said. “They are reluctant to seek help because they fear the stigma will harm them—people won't refer them patients, the hospital might revoke their privileges, and licensing could become a problem.”

State medical licensing boards ask for information on whether the person applying for licensure has been treated for a mental illness, and that information can affect licensing, she said. “I worked with a physician who took lithium,” she said. “The state board made him get blood drawn periodically to prove he continued to take it. That's punitive—they don't do that for other illnesses.”

However, some progress has been made: A total of 19 states now focus specifically on whether an applicant is impaired because of psychiatric illness, she said.

Dr. Clayton's group recently funded the production of three films on physician suicide as part of an ongoing outreach campaign that seeks to educate physicians about depression. One of the films was designed specifically as an educational video for use at medical schools. Because many of the mood disorders that can lead to suicide might become evident first during medical school, where professional and institutional barriers already exist, the goal of that program is to encourage medical students to seek help for depression.

Each day in the United States, roughly one doctor dies by suicide. Studies over the past 4 decades have confirmed that physicians—especially women physicians—die by suicide more frequently than people in other professions or those in the general population.

“Physicians have the means and the knowledge and access to ways to kill themselves,” Dr. Paula Clayton, a psychiatrist and medical director for the American Foundation for Suicide Prevention, said in an interview.

But the data on physicians dying by suicide are difficult to come by, and “we certainly don't have any data that [say] any particular specialty has any higher rates of suicide,” she said.

Although no information is available on the risk of suicide by specialty, researchers do know that physician suicides are equally divided between men and women, whereas in the general population, four times as many men kill themselves as do women, according to Dr. Clayton.

Awareness of the problem remains low, and professional and cultural barriers deter or prevent physicians who are depressed from seeking treatment for their illness, Dr. Clayton said. For example, most physicians do not have a regular source of health care; only 35% of doctors have a personal physician, and even fewer interns and residents have a doctor themselves.

Dr. W. Gerald Austen, surgeon-in-chief emeritus at Massachusetts General Hospital, has first-hand experience. Twenty-eight years ago, when he was surgeon-in-chief, one of his younger staff committed suicide. And about 11 years ago, a surgical resident committed suicide.

Those deaths were the saddest moments of his career, yet Dr. Austen said he doesn't know what could have been done to prevent these young physicians from taking their own lives.

“It wasn't as if the institution and the department weren't aware that they had some problems,” he said in an interview. “Both of these individuals were under psychiatric care. They were believed by both their doctors and their contemporaries and colleagues to be doing rather well.”

In each case, the surgery department reviewed the situation with the psychiatry department, Dr. Austen said, and “we certainly did everything we could in terms of their family in both cases.” But he said the department didn't find any procedures to change internally as a result of the deaths.

It's possible that increasing awareness of physician depression could help get physicians the help they need before it's too late, Dr. Austen said. “Friends who work with people in medicine need to be aware that, if they see something that concerns them, they need to transmit the message to the powers that be.”

But it's difficult to know the difference between someone who is simply unhappy, and someone who is clinically depressed and potentially at risk for suicide, he added. “[Physicians believe] their job is to help other people with problems. If they have a problem themselves, they would prefer to not have people know about it,” said Dr. Austen.

“There's this proudness about their ability to cope,” Dr. Clayton said. “They are reluctant to seek help because they fear the stigma will harm them—people won't refer them patients, the hospital might revoke their privileges, and licensing could become a problem.”

State medical licensing boards ask for information on whether the person applying for licensure has been treated for a mental illness, and that information can affect licensing, she said. “I worked with a physician who took lithium,” she said. “The state board made him get blood drawn periodically to prove he continued to take it. That's punitive—they don't do that for other illnesses.”

However, some progress has been made: A total of 19 states now focus specifically on whether an applicant is impaired because of psychiatric illness, she said.

Dr. Clayton's group recently funded the production of three films on physician suicide as part of an ongoing outreach campaign that seeks to educate physicians about depression. One of the films was designed specifically as an educational video for use at medical schools. Because many of the mood disorders that can lead to suicide might become evident first during medical school, where professional and institutional barriers already exist, the goal of that program is to encourage medical students to seek help for depression.

WASHINGTON – When Dr. David Gregory worked to open a health clinic for the uninsured in 1991, he thought that he would be treating residents of the nearby housing projects. Most of the residents were African Americans.

Since then, however, Siloam Clinic has become the treatment center of choice for a large population of refugees and immigrants from some 100 countries, ranging from Afghanistan to Vietnam.

“Things changed–TennCare [Tennessee's Medicaid program] expanded to include more uninsured patients, and the patients didn't need us so much,” said Dr. Gregory, who is with the division of infectious disease at Vanderbilt University in Nashville, Tenn.

“But one morning, in walked a Vietnamese man. He had spent 9 years as a prisoner of war, and survived torture and forced labor,” he said. “I started looking after him and his wife. It turns out that there were about 4,000 Vietnamese refugees in the area.”

Before Dr. Gregory knew it, word spread among that refugee community that care was available at Siloam at a nominal charge–and the clinic had many new Vietnamese patients.

Now, 80% or so of Siloam's patients are from Nashville's expanding refugee and immigrant population, he said. The clinic's scope of practice includes health screenings, immunizations, primary care, patient education, and specialty care. The clinic receives funding from Medicaid, federal grants, donations, foundations, private insurance, and patient fees.

“Establishing trust [with these individuals and their communities] is dependent on integrity and honesty,” Dr. Gregory said.

A faith-based endeavor that takes its name from biblical references to the Pool of Siloam, the clinic has grown from its humble beginnings in a renovated apartment to a new, debt-free, 12,000-square-foot building that includes 12 examination rooms and a chapel.

The need for this type of community service has grown dramatically since 1991 as the population of uninsured and underinsured grows, Dr. Gregory said. He offered some advice for physicians who, seeing a need in their own communities, want to help.

“What's a doctor to do in the face of these daunting challenges?” he asked. “You can do something, but it takes planning. There are many land mines.”

The first thing Dr. Gregory suggested for those physicians who believe they may want to open a similar clinic is to examine motivation.

“Why are you doing it? Is it altruism? Faith-based? An intellectual challenge? Be honest about why you want to be involved,” he said.

Next, he advised, “do not go alone. If you start talking about it, you'll find people who share this passion.” Then, assemble a board and delegate tasks.

Money obviously is important. “Probably the biggest mistake we made at Siloam was being undercapitalized at the very beginning.” The clinic started with an annual budget of $30,000, he said. In addition, depending entirely or almost entirely on volunteers can be chancy, because volunteers don't always show up to work, he said. Therefore, a clinic of this type should hire paid staff.

At Siloam, patients are expected to pay something. “We're not a free clinic,” Dr. Gregory pointed out. “Patients make a $5 donation. The rationale was to encourage some sense of participation and avoid a sense of this being charity,” Dr. Gregory said. The clinic also asks for patients to pay half the cost of routine lab test fees–for example, a routine complete blood count costs $3.00, so patients pay $1.50, he said, adding, “we get very good wholesale lab prices.”

However, obtaining images and other diagnostic tests has proven more challenging, although Siloam has some testing donated each month, Dr. Gregory said. And to cover patient hospitalizations, the clinic approached Vanderbilt Hospital, which agreed to provide 12 hospitalizations each year; the first year, it cost the hospital $300,000, Dr. Gregory said, but “it keeps the patients out of the emergency room.”

And of course, it's the patients who make all the planning and strategizing worthwhile, he said.

Dr. Gregory spoke of a patient, Abraham, a 25-year-old Sudanese refugee who presented with a week-long history of fever, headache, nausea, vomiting, and weakness. Abraham–a Tennessee resident for 4 years–recently had returned from a 1-month stay in Uganda, where he had been searching for family members.

A physical exam showed a temperature of 102 degrees, no jaundice, but a palpable spleen tip. Dr. Gregory said he started Abraham on mefloquin and confirmed his malaria diagnosis through a peripheral smear that showed falciparum malaria.

One week after treatment for malaria, Abraham felt well but had been fired from his job at a poultry packing company because he was late returning from his Uganda trip, and then was sick for 7 days, Dr. Gregory said. The young man subsequently found a better job.

Dr. David Gregory says his health clinic for the uninsured is now debt free. Joicelyn Gregory

WASHINGTON – When Dr. David Gregory worked to open a health clinic for the uninsured in 1991, he thought that he would be treating residents of the nearby housing projects. Most of the residents were African Americans.

Since then, however, Siloam Clinic has become the treatment center of choice for a large population of refugees and immigrants from some 100 countries, ranging from Afghanistan to Vietnam.

“Things changed–TennCare [Tennessee's Medicaid program] expanded to include more uninsured patients, and the patients didn't need us so much,” said Dr. Gregory, who is with the division of infectious disease at Vanderbilt University in Nashville, Tenn.

“But one morning, in walked a Vietnamese man. He had spent 9 years as a prisoner of war, and survived torture and forced labor,” he said. “I started looking after him and his wife. It turns out that there were about 4,000 Vietnamese refugees in the area.”

Before Dr. Gregory knew it, word spread among that refugee community that care was available at Siloam at a nominal charge–and the clinic had many new Vietnamese patients.

Now, 80% or so of Siloam's patients are from Nashville's expanding refugee and immigrant population, he said. The clinic's scope of practice includes health screenings, immunizations, primary care, patient education, and specialty care. The clinic receives funding from Medicaid, federal grants, donations, foundations, private insurance, and patient fees.

“Establishing trust [with these individuals and their communities] is dependent on integrity and honesty,” Dr. Gregory said.

A faith-based endeavor that takes its name from biblical references to the Pool of Siloam, the clinic has grown from its humble beginnings in a renovated apartment to a new, debt-free, 12,000-square-foot building that includes 12 examination rooms and a chapel.

The need for this type of community service has grown dramatically since 1991 as the population of uninsured and underinsured grows, Dr. Gregory said. He offered some advice for physicians who, seeing a need in their own communities, want to help.

“What's a doctor to do in the face of these daunting challenges?” he asked. “You can do something, but it takes planning. There are many land mines.”

The first thing Dr. Gregory suggested for those physicians who believe they may want to open a similar clinic is to examine motivation.

“Why are you doing it? Is it altruism? Faith-based? An intellectual challenge? Be honest about why you want to be involved,” he said.

Next, he advised, “do not go alone. If you start talking about it, you'll find people who share this passion.” Then, assemble a board and delegate tasks.

Money obviously is important. “Probably the biggest mistake we made at Siloam was being undercapitalized at the very beginning.” The clinic started with an annual budget of $30,000, he said. In addition, depending entirely or almost entirely on volunteers can be chancy, because volunteers don't always show up to work, he said. Therefore, a clinic of this type should hire paid staff.

At Siloam, patients are expected to pay something. “We're not a free clinic,” Dr. Gregory pointed out. “Patients make a $5 donation. The rationale was to encourage some sense of participation and avoid a sense of this being charity,” Dr. Gregory said. The clinic also asks for patients to pay half the cost of routine lab test fees–for example, a routine complete blood count costs $3.00, so patients pay $1.50, he said, adding, “we get very good wholesale lab prices.”

However, obtaining images and other diagnostic tests has proven more challenging, although Siloam has some testing donated each month, Dr. Gregory said. And to cover patient hospitalizations, the clinic approached Vanderbilt Hospital, which agreed to provide 12 hospitalizations each year; the first year, it cost the hospital $300,000, Dr. Gregory said, but “it keeps the patients out of the emergency room.”

And of course, it's the patients who make all the planning and strategizing worthwhile, he said.

Dr. Gregory spoke of a patient, Abraham, a 25-year-old Sudanese refugee who presented with a week-long history of fever, headache, nausea, vomiting, and weakness. Abraham–a Tennessee resident for 4 years–recently had returned from a 1-month stay in Uganda, where he had been searching for family members.

A physical exam showed a temperature of 102 degrees, no jaundice, but a palpable spleen tip. Dr. Gregory said he started Abraham on mefloquin and confirmed his malaria diagnosis through a peripheral smear that showed falciparum malaria.

One week after treatment for malaria, Abraham felt well but had been fired from his job at a poultry packing company because he was late returning from his Uganda trip, and then was sick for 7 days, Dr. Gregory said. The young man subsequently found a better job.

Dr. David Gregory says his health clinic for the uninsured is now debt free. Joicelyn Gregory

WASHINGTON – When Dr. David Gregory worked to open a health clinic for the uninsured in 1991, he thought that he would be treating residents of the nearby housing projects. Most of the residents were African Americans.

Since then, however, Siloam Clinic has become the treatment center of choice for a large population of refugees and immigrants from some 100 countries, ranging from Afghanistan to Vietnam.

“Things changed–TennCare [Tennessee's Medicaid program] expanded to include more uninsured patients, and the patients didn't need us so much,” said Dr. Gregory, who is with the division of infectious disease at Vanderbilt University in Nashville, Tenn.

“But one morning, in walked a Vietnamese man. He had spent 9 years as a prisoner of war, and survived torture and forced labor,” he said. “I started looking after him and his wife. It turns out that there were about 4,000 Vietnamese refugees in the area.”

Before Dr. Gregory knew it, word spread among that refugee community that care was available at Siloam at a nominal charge–and the clinic had many new Vietnamese patients.

Now, 80% or so of Siloam's patients are from Nashville's expanding refugee and immigrant population, he said. The clinic's scope of practice includes health screenings, immunizations, primary care, patient education, and specialty care. The clinic receives funding from Medicaid, federal grants, donations, foundations, private insurance, and patient fees.

“Establishing trust [with these individuals and their communities] is dependent on integrity and honesty,” Dr. Gregory said.

A faith-based endeavor that takes its name from biblical references to the Pool of Siloam, the clinic has grown from its humble beginnings in a renovated apartment to a new, debt-free, 12,000-square-foot building that includes 12 examination rooms and a chapel.

The need for this type of community service has grown dramatically since 1991 as the population of uninsured and underinsured grows, Dr. Gregory said. He offered some advice for physicians who, seeing a need in their own communities, want to help.

“What's a doctor to do in the face of these daunting challenges?” he asked. “You can do something, but it takes planning. There are many land mines.”

The first thing Dr. Gregory suggested for those physicians who believe they may want to open a similar clinic is to examine motivation.

“Why are you doing it? Is it altruism? Faith-based? An intellectual challenge? Be honest about why you want to be involved,” he said.

Next, he advised, “do not go alone. If you start talking about it, you'll find people who share this passion.” Then, assemble a board and delegate tasks.

Money obviously is important. “Probably the biggest mistake we made at Siloam was being undercapitalized at the very beginning.” The clinic started with an annual budget of $30,000, he said. In addition, depending entirely or almost entirely on volunteers can be chancy, because volunteers don't always show up to work, he said. Therefore, a clinic of this type should hire paid staff.

At Siloam, patients are expected to pay something. “We're not a free clinic,” Dr. Gregory pointed out. “Patients make a $5 donation. The rationale was to encourage some sense of participation and avoid a sense of this being charity,” Dr. Gregory said. The clinic also asks for patients to pay half the cost of routine lab test fees–for example, a routine complete blood count costs $3.00, so patients pay $1.50, he said, adding, “we get very good wholesale lab prices.”

However, obtaining images and other diagnostic tests has proven more challenging, although Siloam has some testing donated each month, Dr. Gregory said. And to cover patient hospitalizations, the clinic approached Vanderbilt Hospital, which agreed to provide 12 hospitalizations each year; the first year, it cost the hospital $300,000, Dr. Gregory said, but “it keeps the patients out of the emergency room.”

And of course, it's the patients who make all the planning and strategizing worthwhile, he said.

Dr. Gregory spoke of a patient, Abraham, a 25-year-old Sudanese refugee who presented with a week-long history of fever, headache, nausea, vomiting, and weakness. Abraham–a Tennessee resident for 4 years–recently had returned from a 1-month stay in Uganda, where he had been searching for family members.

A physical exam showed a temperature of 102 degrees, no jaundice, but a palpable spleen tip. Dr. Gregory said he started Abraham on mefloquin and confirmed his malaria diagnosis through a peripheral smear that showed falciparum malaria.

One week after treatment for malaria, Abraham felt well but had been fired from his job at a poultry packing company because he was late returning from his Uganda trip, and then was sick for 7 days, Dr. Gregory said. The young man subsequently found a better job.

Dr. David Gregory says his health clinic for the uninsured is now debt free. Joicelyn Gregory

WASHINGTON – Analysis of other countries' health care systems has pointed out what might work–and what won't work–in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned from health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, and Japan) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

“Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care,” the ACP position paper said.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility–such as those found in Australia, Belgium, Japan, and other countries–can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims–as has been done in Germany, Canada, and Taiwan, among others–improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology result in reliance on outdated technologies and equipment, and delay patients' access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper said. Much of this information is shared through the Network of Agencies for Health Technology Assessment, of which the U.S. Agency for Healthcare Research and Quality (AHRQ) is a member, the paper said.

WASHINGTON – Analysis of other countries' health care systems has pointed out what might work–and what won't work–in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned from health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, and Japan) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

“Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care,” the ACP position paper said.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility–such as those found in Australia, Belgium, Japan, and other countries–can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims–as has been done in Germany, Canada, and Taiwan, among others–improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology result in reliance on outdated technologies and equipment, and delay patients' access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper said. Much of this information is shared through the Network of Agencies for Health Technology Assessment, of which the U.S. Agency for Healthcare Research and Quality (AHRQ) is a member, the paper said.

WASHINGTON – Analysis of other countries' health care systems has pointed out what might work–and what won't work–in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned from health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, and Japan) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

“Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care,” the ACP position paper said.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility–such as those found in Australia, Belgium, Japan, and other countries–can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims–as has been done in Germany, Canada, and Taiwan, among others–improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology result in reliance on outdated technologies and equipment, and delay patients' access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper said. Much of this information is shared through the Network of Agencies for Health Technology Assessment, of which the U.S. Agency for Healthcare Research and Quality (AHRQ) is a member, the paper said.