Another
care programs is worse than that in other
develops a less expensive method of delivering
countries, even where populations are aging
superior outcomes and is willing to stake its
alternative would
more dramatically. In many countries, bud-
reputation on it, that corporation should have
be for states to
the opportunity to compete. We will take qual-
getary limits force health care spending to
recognize
ity care from anyone.
stay within a fixed target. Under Medicare,
with fee-for-service reimbursement, we have
Corporations providing health care would
clinician licenses
no effective spending control mechanism.
be evaluated by consumers, both informally
issued by other
The Congressional Budget Office has point-
through word of mouth and formally on web-
states.
ed out that our health care sector's excess
sites, in magazines, and by consumer groups.
cost growth, in which spending continues to
Just as in any other market, corporations
grow faster than the GDP, is unsustainable.
would have an incentive to attain good reputa-
Better ways of delivering medical care are
tions.
available. But without entrepreneurial mech-
The market regulates quality by driving
anisms, market incentives, and vigorous
inferior firms out of business. If that process
competition, these approaches tend to
is insufficient, then government regulators
remain isolated exceptions, rather than gen-
could be empowered to license and revoke
eral practice.
licenses of corporate health care providers.
Eventually, we will have to consider radi-
Note that with any regulatory system, the
cal new ways to organize health care delivery.
regulated entities will attempt to "capture" the
To improve health care quality and to reduce
regulator and to use regulations to restrict
its cost, we need to eliminate barriers to com-
competition. Under our current system of reg-
petition by corporations.
ulating individual practitioners, the revocation
of licenses is a step rarely taken. Economist
Shirley Svorny writes that "state boards have a
Notes
poor record of disciplining errant physicians"
and that "one might conclude that licensure
1. Elliott Fisher, "Expert Voices: More Care Is Not
offers more protection to malfeasant clinicians
Better Care," National Institute for Health Care
than to consumers."21 This is another way in
Management 7 (2005), www.nihcm.org/~nihcmor
/pdf/ExpertV7.pdf.
which our current regulatory structure favors
the provider, not the patient. The net benefits
2. Elizabeth A. McGlynn et al., "The Quality of
(or costs) of institutional licensing would have
Health Care Delivered to Adults in the United
States," New England Journal of Medicine 348, no. 26
to be weighed against the net costs of the cur-
(2003): 263545. See also Steven M. Asch et al.,
rent system of licensing individual medical
"Who Is at Greatest Risk for Receiving Poor-
professionals.
Quality Health Care?" New England Journal of
Another alternative would be for states to
Medicine 354, no. 11 (2006): 114756.
recognize clinician licenses issued by other
3. Institute of Medicine, To Err Is Human: Building
states.22 That would let health care corpora-
a Safer Health System (Washington: National
tions operate in multiple states under a single
Academy Press, 2000).
set of licensing regulations, and would put pres-
4. "Chronically Ill Patients Get More Care, Less
sure on states to eliminate regulations that are
Quality, Says Latest Dartmouth Atlas: The Fix? A
unnecessarily restrictive. Each state could take
Major Overhaul of Medicare," The Dartmouth
that step on its own, or Congress could require
Institute for Health Policy and Clinical Practice /
states to recognize each other's licenses.
Robert Wood Johnson Foundation, Press Release,
2008, www.dartmouthatlas.org/press/2008_At
las_press_release.pdf.
Conclusion
5. See, for example, Alain C. Enthoven and Laura
A. Tollen, eds., Toward a 21st Century Health System:
America needs real reform in health care.
The Contributions and Promise of Prepaid Group
Practice (San Francisco: Jossey-Bass, 2004), and
The fiscal outlook for our government health
8