Intended for healthcare professionals

Analysis Essay

Why the US healthcare system is failing, and what might rescue it

BMJ 2012; 344 doi: (Published 09 May 2012) Cite this as: BMJ 2012;344:e3052
  1. Arnold Relman, professor emeritus of medicine and social medicine, Harvard Medical School, Boston, Massachusetts, USA
  1. arnoldrelman{at}

The US healthcare system is by far the most expensive in the world, but it now leaves about 50 million of its citizens totally without coverage and fails to provide adequate protection for millions more. And the quality of care is on average inferior to that of countries that spend much less. Can the rise of multispecialty groups make US medical care much more affordable and efficient?

The US healthcare system seems headed for bankruptcy because of its ever increasing and unsustainable costs. These costs will be effectively controlled only by legislative reforms in the insurance and payment for medical care, but the prospects of such legislation will depend on a more favourable political climate and stronger public support. However, legislation will accomplish little unless the organisation of medical services also changes. The recent movement of US physicians into large multispecialty groups suggests that this reorganisation of medical care may already be under way. If this trend continues, it could not only facilitate the enactment of legislation, but also help to make our medical care much more affordable and efficient.

At present, most US physicians are in solo practice or belong to small, single specialty partnerships, but new social and economic forces are beginning to make employment in large multispecialty groups a more attractive option. About a quarter of all US practitioners are now employed in such groups, which are being formed by independent physician organisations and by hospitals. If their number continues to increase and if they eventually represent the great majority of practising physicians, a wave of legislative reforms could be initiated that transforms our currently dysfunctional healthcare system. But before I say more about this move towards group practice and how it might improve prospects for reform, readers need to understand how and why our health system …

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