The U.S. continues to have the highest cost per capita – twice what other major industrialized countries spend – for health care, and has dropped to last among 19 countries on a measure of mortality amenable to medical care. So reports the Commonwealth Fund Commission on a High Performance Health System in its recent report, titled “Why Not the Best?” Overall performance did not improve in this country from 2006 to 2008, compared to gains recorded in other countries. Why not the best, indeed?

We spend more and more money with nothing to show for it. What’s wrong with our system? Is it the number of Americans who have little or no health insurance? Is it the lack of adequate preventive care? Is it the lack of an appropriate primary care (“medical home”) system? Is it the greedy doctors and pharmaceutical companies? Is it the lack of adequate medical data collection, analysis and incentive to change what doctors and hospitals are doing? Perhaps the whole system is broken.

If it is, there is no easy fix. To be the best in quality of care as well as cost efficiency, reform has to start at the top, with leadership from the new President and Congress. Major reform costs money in the short term, saves money in the long term. Here are the steps I believe are essential:

1. Make sure all Americans have access to the health care they need. As of 2007, 75 million adults – 42% of those between the ages of 19 and 64 – were uninsured or underinsured. Just one more example of our country’s failure to live up to the principle of equality! There are several proposals afloat for how to do this. The basis for success must be a single system (not necessarily single payer) for all – not one for poor people, nor one for old people. We all deserve the same access to quality of care. If necessary for cost control, I would accept a means test – based on the IRS approach to taxation – to determine how much each of us pays for the same right to care.

2. Emphasize first-line care, including prevention. That means rewarding primary care practices that use teamwork to spend more time in examining patients, counseling them on healthy lifestyles, maintaining care for those with chronic diseases, those who are pregnant, those with addictions. A recent NY Times article described medical-home experiments underway in various parts of the country. A new report from the Trust for America’s Health stated that an investment of $10 per person per year in proven community based programs to increase physical activity, improve nutrition and prevent smoking could save the country more than $16 billion annually within 5 years – a 5.6 return on investment.

3. Provide incentives to physicians and hospitals to improve performance. This is already under way to a limited extent in the Federal government’s program to increase reimbursement for performance on a number of critical indicators in a number of specialties. Unfortunately, most medical practices lack electronic medical record systems, which would enable them not only to track performance but also to instantly compare performance to accepted guidelines for care. Only 28% of U.S. physicians have such systems, compared to 98% in the Netherlands and 89% in the UK. Incentives are needed to improve teamwork in care, to coordinate long-term care, and to reduce errors ranging from hospital safety to failure to have test records available for review when a patient arrives. In addition, there are major gaps in performance and cost between leaders and laggards, both in hospitals and in medical practices. Incentives might then include mandatory educational programs for the laggards, with rewards for improvement.

4. Reduce administrative costs. Even if we retain the mix of private and public health insurance systems, we can do better. The Commonwealth Fund report estimates we could save $51 billion by reducing our costs to those of countries with similar systems – Germany, the Netherlands and Switzerland.

What are we waiting for? Are we prepared to have spending rise from 17% of GDP to 25% without improving the quality of care? Remember, it could mean the life or ability to function of your grandmother or three-month-old infant.