Commentary on an Excerpt From A Tale of Two Cities

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The opening passage from A Tale of Two Cities by Charles Dickens is one of the most recognized beginnings in modern literature. Here Dickens sets the stage for a tale that chronicles the events leading up to the French Revolution. In these first few lines, Dickens establishes the novel’s primary theme of duality while also illustrating the enduring dichotomous climate of rampant social disparities between the French bourgeoisie and aristocracy.
Dickens’s timeless introduction bears a resemblance to the current climate of health care in the United States—a realm undergoing its own disruptive revolution. Over the past several decades, technological progress has created staggering advances in pharmaceuticals and medical procedures. Additionally, genomics, proteomics, and metabolomics have begun to deliver on the promise of individually tailored care that can maximize benefit and minimize harm. These advances have benefited millions around the globe, and U.S. academic and medical-industrial institutions are leading much of this progress. These should be the best of times.
Yet, we have discovered that hospital errors in the United States are the eighth leading cause of death, that as much as one-third of U.S. health care spending is considered “waste,” that there are major gaps in the delivery of care even to those who have no socioeconomic barriers to access, and that, in fact, one of the wealthiest countries on the planet endures enormous racial and ethnic disparities in care.1–3 Indeed, while recent strides in medical innovation may have many of us in health care thinking that we are approaching medicine’s Age of Enlightenment, we find ourselves still stumbling in the dark. In many senses, it is the best of times, it is the worst of times.
Similar to the great gulfs among the French people that inspired the French Revolution, the gaps in who in the United States fully benefits from recent innovations have spurred a national revolution of health care reform. Reformers hope to bridge the chasm in quality and equity, to safely apply medical advances to all.
To depict this impending paradigm shift, John T. Fox, the former chief executive officer of Emory Healthcare, introduced an analogy of two distinct worlds—World A and World B. While World A is predominantly characterized by the prevailing fee-for-service model in which volume drives much of the output, World B embraces a new value-based proposition that promises to deliver high-quality care at a reasonable cost by incentivizing outcomes and rewarding continuous, coordinated care. Additionally, World B and its initiatives, which are tailored toward ameliorating chronic conditions that disproportionately affect minorities, offer the real opportunity to bridge gaps in social disparities.4
While many welcome World B and the opportunities it presents for implementing new care models, others are nostalgic for what they perhaps recall as the “good old days” of medicine. In reality, each world has its own advantages and disadvantages. World A has served us well, providing the infrastructure for the innovations that have benefited so many. Moreover, a sudden transition to World B, even if desirable, would risk chaotically disrupting a sizeable portion of the U.S. economy. In fact, there are growing concerns that World B and its policies, which are intended to improve quality, may inadvertently widen the disparity gap by disproportionately penalizing “safety-net” health care systems or by creating perverse incentives for providers to avoid high-risk patients who are often from underserved racial or ethnic minorities.5 As such, ensuring that equity, not just quality, is a definitive value in any value-based health care world is imperative.
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