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PHILADELPHIA -- How do other countries achieve better health outcomes than the U.S.? They all have three traits that the U.S. does not, Paul Keckley, PhD, said at the Population Health Colloquium here.

Keckley, who is now a health consultant based in Nashville, Tennessee, recalled a time in 2009 during the Obama administration when he moderated discussions at the White House between various healthcare interest groups -- including drugmakers, health insurers, and device makers -- about the best way to reform the U.S. healthcare system that would allow everyone to be covered while also reducing costs and improving quality.

"Every sector and sub-sector of healthcare has its piece figured out and thinks the others are the ones that really don't have religion," he said. But when White House officials studied the countries whose healthcare systems outperformed that of the U.S., three characteristics stood out:

• The other countries had global budgets for healthcare. Those countries decided that "there's a fixed amount of money we're going to spend," Keckley said. "You think that's going to happen [here]?"
• The other countries had national standards of care. "There was a standard of care that the government oversaw," he said. "We don't [have that] ... We let everybody determine what's appropriate care, and then we defend it."
• The other countries made primary care the central form of care. However, there was a caveat to that, said Keckley: "It wasn't [about] health or social services. It was health and social services, funded directly by taxes at 2.5 times what we spend in the U.S. on social services, and in which behavioral and physical medicine, prophylactic dentistry, and over-the-counter and prescription drugs were integrated into those models of primary health. That sounded pretty good to me."

During those discussions, "everybody at the table had suggestions -- and all of those suggestions involved something somebody else at the table needed to change," he said. "Does that sound familiar?"

Keckley also had discussions with committees on Capitol Hill, "and no one seemed to understand who played in healthcare," he said. Meanwhile, out in the larger healthcare world, "everybody in this ecosystem has their own business models, their own sources of capital, their own ways of defining emergent technologies. They have their own 'advocacy cocktails' -- local, state, federal, some more effective than others -- and everyone was doing reasonably well, because this engine breathes its own smoke."

"Here's what we know; we know that this is not sustainable," Keckley said. "And we know that in the election cycle of 2024, it won't matter much because we've got dysfunction between the parties, and there are a lot of reasons for that. But in '26 and '28, we know that more than half the population right now says, 'This thing's too complicated. It's too expensive. It's not working, and I'm open to something better.'"

So what should happen with U.S. healthcare in the future? "Does this become a regulated service?" he asked. "Do we have a bifurcated public-private system in which 15% of the population buys [insurance through] a private model and 85% through a government model, or any iteration of those? This cocktail of labor-intense, capital-intense fragmentation is not sustainable."

Better coordination of care can start with primary care physicians themselves, said Jeffrey Brenner, MD, CEO of the Jewish Board of Family and Children's Services here. He recalled a time 25 years ago when he started up in private practice as a family physician in Camden, New Jersey.

"I loved my little practice, and I was seeing some of the most complex patients I'd ever seen in my career, one after another after another," said Brenner, who in 2013. "And what I learned pretty quickly is that I could add real value to their lives."

"I could really impact people by doing a couple of things," he continued. "One was that I wouldn't send them to the specialist. Instead, I would pick up the phone and I'd call the specialist, because when I sent them to the specialist, because of literacy barriers, English barriers, and all sorts of barriers, they just never really got that good of care. So I would call and I'd get consults myself."

"I would also coordinate a lot of their care myself, and I would end up calling them with their test results myself," Brenner said. "And pretty quickly, I had more and more complex people showing up because they'd heard they would get kind of very personalized care ... and the practice got bigger and bigger and more and more crowded."

"And if you think back 25 years ago, the dominant conversation we were having everywhere ... was that healthcare is disorganized, it's fragmented, and it's confusing," which is still true today, he said. "It led me to believe that if we organized care for very complex and sick people, we could make a difference." So Brenner organized a breakfast group that eventually turned into the Camden Coalition of Healthcare Providers.

"We had hospitals on our board, all the primary care offices in Camden, patients, and social service agencies," Brenner explained. "We also started a health information exchange very early, so you had seamless access to all the major healthcare data across any practice in the city ... We were doing all sorts of things in the city to help patients get in within 7 days, we were doing diabetes collaboratives -- all the stuff we talk about in population health."

Healthcare systems, whether they were primary care practices or federally qualified health clinics, "have become built for the average consumer, the average person" and not the more complex "outlier" patients, said Brenner. "The system outliers are frustrating; they don't fit in your nice queues. Ultimately, what I think we need is more segmentation ... We have to put complex people in their own clinical models."

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