Achieving a High Performance Health System:What Will it Take?

2006 Priester National Health ConferenceApril 27, 2006

Anne GauthierSenior Policy Director

The Commonwealth Fundwww.cmwf.org

Presentation OverviewPresentation Overview

• Current U.S. health care system performance

• Keys to transforming our system

• Roles for educators

Commonwealth Fund Commission on a Commonwealth Fund Commission on a High Performance Health SystemHigh Performance Health System

• GOAL: Move the U.S. toward a higher-performing health care system that achieves better access, improved quality, and greater efficiency, with particular focus on the most vulnerable due to income, race/ethnicity, health, or age.

• STRUCTURE: 18 members; Chaired by Jim Mongan, President and CEO of Partners Health Care, Boston, MA; 3 meetings per year

• CHALLENGE: The Commission must focus on the “substantive few” critical issues that can accelerate performance improvement in the U.S. health care system. It will need to seek and recommend innovative ways to get these issues onto the public and private policy agendas.

• INITIAL PRODUCTS: Chartbook on current performance and briefs on critical national policy issues (available at www.cmwf.org). Framework for a high performance health system (June 2006). Annual performance scorecard (August 2006).

Dimensions of a High Dimensions of a High Performance Health SystemPerformance Health System

• Long and healthy lives• Getting the right care • Coordinated care over time • Safe care • Patient-centered care/service excellence• Efficient, high-value care• Affordable care• Universal participation• Equitable care• System has the capacity to improve and

innovate

Long and Healthy LivesLong and Healthy Lives

Mortality Amenable to Health Care, Mortality Amenable to Health Care, 19981998

97 97 99106 107 109 109

115 115

129 130 132

7584 88 88 88

8192

0

20

40

60

80

100

120

140

Deaths per 100,000 population*

* Countries’ age standardized death rates, age 0-74Note: Includes ischemic heart diseaseSource: E. Nolte and M. McKee,“Measuring the Health of Nations: Analysis of Mortality Amenable to Health Care,” British Medical Journal, November 15, 2003.

Getting the Right CareGetting the Right Care

U.S. Adults Receive Half of Recommended Care, U.S. Adults Receive Half of Recommended Care, and Quality Varies Significantly by Medical and Quality Varies Significantly by Medical

ConditionCondition

Source: E. McGlynn et al. 2003. "The Quality of Health Care Delivered to Adults in the United States,"The New England Journal of Medicine 248(26): 2635–2645.

55

7665

5445

39

23

0

20

40

60

80

Overall Breast

Cancer

Hypertension Asthma Diabetes Pneumonia Hip Fracture

Percent of recommended care received

Provision of Appropriate CareProvision of Appropriate Care

First

Third

Fourth

Source: S.F. Jencks, E.D. Huff, and T. Cuerdon. 2003. “Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998–1999 to 2000–2001,” Journal of the American Medical Association 289(3): 305–312.

Second

WA

OR

ID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SC

TNNC

KY

FL

VA

OH

MI

WV

PA

NY

MD

MEVT

NH

MA

RI

CT

DE

DCCO

GAMS

OK

NJ

SD

Quartile Rank

Note: State ranking based on 22 Medicare performance measures.

Performance on Medicare Quality IndicatorsPerformance on Medicare Quality Indicators2000–20012000–2001

HI

AK

Coordinated Care Over TimeCoordinated Care Over Time

33% Patients in the U.S. Experience 33% Patients in the U.S. Experience Care Coordination ProblemsCare Coordination Problems

Percent saying in the past 2 years:

AUS CAN GER NZ UK US

Test results or records not available at time of appointment

12 19 11 16 16 23

Duplicate tests: doctor ordered test that had already been done

11 10 20 9 6 18

Percent who experienced either coordination problem

19 24 26 21 19 33

Source: Schoen et al., 2005. “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” Health Affairs Web Exclusive November 3, 2005. Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

Length of Time With Regular Length of Time With Regular Doctor/Place of CareDoctor/Place of Care

Percent: AUS CAN GER NZ UK US

Has Regular Doctor/Place 92 92 97 94 96 84

Less than 2 years 16 12 6 19 14 17

3 to less than 5 years

20 20 15 18 16 25

5 years or more 56 60 76 57 66 42

No regular doctor/place 8 8 3 6 4 16

Source: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

Safe CareSafe Care

Percent of sicker adults reporting medical or medication error that caused serious health problem in past two years:

Large Percentage of Adults Report Large Percentage of Adults Report Medication ErrorsMedication Errors

5146

54

42 4541

0

20

40

60

80

AUS CAN NZ UK US GER

SOURCE: Schoen et al.,2005. “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” Health Affairs Web Exclusive November 3, 2005.Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

Patient-Centered Care/ Patient-Centered Care/ Service ExcellenceService Excellence

Opportunities Exist for Enhanced Opportunities Exist for Enhanced Doctor–Patient Communication and Doctor–Patient Communication and

InteractionsInteractions

Percent saying doctor: AUS CAN NZ UK US

Always listens carefully 71 66 74 68 58

Always explains things so you can understand

73 70 73 69 58

Always spends enough time with you

63 55 66 58 44

Source: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care.

Efficient, High Value CareEfficient, High Value Care

Cartoonstock.com

Cost and Quality VaryCost and Quality VaryWidely Across Widely Across HospitalsHospitals

Coronary Artery Bypass Graft: Observed/Expected Cost vs. Observed/Expected Quality

Outcomes by Hospital

0.0

0.5

1.0

1.5

2.0

0.0 0.5 1.0 1.5 2.0 2.5

Poor Outcomes - Observed/Expected

Co

st p

er C

ase

- O

bse

rved

/Exp

ecte

d

High Quality Low Quality

High Cost

Low Cost

Source: S. Grossbart, Ph.D., Director, Healthcare Informatics, Premier, Inc. 2003. “The Business Case for Safety and Quality: What Can Our Databases Tell Us,” 5 th Annual NPSF Patient Safety Congress, March 15.

Variation in Hospital Mortality and Variation in Hospital Mortality and Cost Per PatientCost Per Patient

-5

-4

-3

-2

-1

0

1

2

3

4

5

6

-4 -2 0 2 4 6

Risk-adjusted mortality (Z-value), 2001

Sev

erit

y ad

just

ed c

ost

(Z

-val

ue)

, 200

1

Note: The data are based on 10 HCUP states, and the mortality is a weighted composite of 10 risk-adjusted inpatient mortality rates. The cost has been adjusted for wage index, case mix, and severity of illness. Source: H. Joanna Jiang, Ph.D.; Center for Delivery, Organization and Markets; Agency for Healthcare Research and Quality

Affordable CareAffordable Care

23

10

2

29

11

0

10

20

30

40

Total Less than

$20,000

$20,000–

$34,999

$35,000–

$59,999

$60,000 or

more

Spent 5% or more of income on out-of-pocket costs

Adults with Low and Moderate Incomes Adults with Low and Moderate Incomes Spend High Share of Income onSpend High Share of Income on

Out-of-Pocket CostsOut-of-Pocket Costs

Source: Collins, Doty, Davis et al. 2004. “The Affordability Crisis in U.S. Health Care: Findings from The Commonwealth Fund Biennial Health Insurance Survey”. The Commonwealth Fund.

Percent of adults ages 19–64 insured all year with private insurance

Note: Income groups based on 2002 household income.

Universal ParticipationUniversal Participation

Percent of Adults 19-64 Percent of Adults 19-64 Uninsured by StateUninsured by State

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVT

NH

MARI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SCTN

NC

KY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVT

NH

MARI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

19–23.9%

Less than 14%

14–18.9%

24% or more

1999–20001999–2000 2003–20042003–2004

Source: Two-year averages 1999-2000 and 2003-2004 from the Census Bureau’s March Current Population Survey (CPS: Annual Social and Economic Supplements). Estimates by EBRI.

Equitable CareEquitable Care

63 6359

65

53 5548

60

0

40

80

All races White Black Hispanic

Low poverty, <10% High poverty, 20%+

Percent of women diagnosed with cancer, 1988–1994

Five-Year Survival Rates for Cancer Patients Five-Year Survival Rates for Cancer Patients Vary by Race/Ethnicity and Census Poverty TractVary by Race/Ethnicity and Census Poverty Tract

Source: G. Singh et al. 2003. “Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality, Stage, Treatment and Survival, 1975–1999,” NCI. Figures 6.3 and 6.4.

*Children who have a primary care provider who provides accessible, coordinated and preventive care. ** High income refers to household incomes ≥400% of Federal poverty level; and Poor, <100% of poverty level.

SOURCE: 2003 National Survey of Children’s Health; Retrieved from www.nschdata.org

30

39

53

23

53

31

58

36

60

46

0 20 40 60 80

Hispanic

Black

White

Uninsured

Private Insurance

Poor

High Income

Bottom 5 States

Top 5 States

National

**

Medical Home for Children, 2003Medical Home for Children, 2003Percent of children who have a medical home*

System Capacity to Improve and System Capacity to Improve and InnovateInnovate

20

3339

5043

32

47

35

24

34

0

50

100

Redesign Efforts Collaborative Efforts*

Total 10–49 Physicians1 Physician 50+ Physicians2–9 Physicians

Percent indicating involvement in redesign and collaborative efforts

Physicians’ Participation in Redesign and Physicians’ Participation in Redesign and Collaborative Activities, by Practice SizeCollaborative Activities, by Practice Size

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

* Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years.

The $2.0 Trillion Question:The $2.0 Trillion Question:

Q: How are we going to get from where we are to where we could/should be?

A: We’re not, unless we change the way we play the game

Key Pieces to Transforming the U.S. Key Pieces to Transforming the U.S. Health Care SystemHealth Care System

1. Achieve universal participation2. Organize care and information around the patient3. Expand primary care and preventative services4. Expand use of interoperable information technology5. Reward performance6. Enhance quality and value of care7. Encourage collaboration

Universal ParticipationUniversal Participation

1. Achieve Universal Participation

Growing Number of Uninsured and Underinsured Growing Number of Uninsured and Underinsured AmericansAmericans

Insured All Year, Not Underinsured

65%

Underinsured9%

Uninsured All Year13%

Uninsured Part Year13%

Source: C. Schoen et al. 2005. “Insured but Not Protected: How Many Adults Are Underinsured?” Health Affairs Web Exclusive, June 14, 2005. Based on The Commonwealth Fund 2003 Biennial Health Insurance Survey.

Uninsured is defined as uninsured for some time during the past year. Underinsured defined as family out of pocket expenses represent at least 10% or more of income, family out of pocket expenses for low-income represents at least 5% of income or deductibles represent 5% of income

Uninsured and Underinsured are More Likely Uninsured and Underinsured are More Likely to Have Access Barriers, Problems with to Have Access Barriers, Problems with

Medical Bills and Be Dissatisfied with Care Medical Bills and Be Dissatisfied with Care

15%

9% 11%7%

9%

38% 38%

44%

28%23%

38%

30%

46%

35%32%

0%

10%

20%

30%

40%

50%

Did Not Fill aPrescription

SkippedRecommended

Care

Contacted byCollections Agency

Changed Way ofLife to Pay Medical

Bills

Very or SomewhatDissatisfied withQuality of Care

Insured Uninsured Underinsured

Access Barriers Due to Cost Problems With Medical Bills

Source: C. Schoen et al., 2005. “Insured but Not Protected: How Many Adults Are Underinsured?” Health Affairs Web Exclusive, June 14, 2005. Based on The Commonwealth Fund 2003 Biennial Health Insurance Survey.

Percent Experiencing Problem in Past Year

Options for Expanding CoverageOptions for Expanding Coverage• Mixed public insurance/private insurance strategy

– Improve coverage

– Ensure adequate benefits

– Provide financial protection

• Expand public programs

– Federal Employees Health Benefits Program

– Medicare

– State Children’s Health Insurance Program

• Provide financial assistance to workers and employers to afford coverage

• Pool purchasing power to make coverage more affordable

• Promote new benefit designs to make coverage more affordable

• Mandate employers to offer and/or individuals to purchase coverage; subsidize those below x% of poverty

Organize Care and Information Organize Care and Information Around the PatientAround the Patient

1. Achieve Universal Participation

2. Organize care and Information

Around the Patient

Those with Less Choice of Where Medical Those with Less Choice of Where Medical Care Is Received Are Less Likely to Be Care Is Received Are Less Likely to Be

Satisfied with Their Health CareSatisfied with Their Health Care

4

10

24 26

0

25

50

Great deal ofchoice

Fair amount ofchoice

Not too muchchoice

No choice

Percent of adults 19–64 with employer-sponsored insurance who are “somewhat” or “very dissatisfied” with their health care

Source: Jeanne Lambrew 2005. “Choice’ in Health Care: What Do People Really Want?” The Commonwealth Fund, September 2005.

Options for Organizing Care and Options for Organizing Care and Information Around PatientInformation Around Patient

• Insurers and providers can promote shared decision making by:– Providing tools to assist with health care

decisions (e.g., videotapes, booklets, websites)– Providing follow-up counseling with skilled staff– Requiring shared decision-making education for

elective procedures– Making personal health records and data

accessible to patients and their providers

• Purchasers can reward plans that emphasize patient-centered care

Expand Primary Care and Expand Primary Care and Preventative ServicesPreventative Services

1. Achieve Universal Participation

2. Organize care and Information

Around the Patient

3.Expand Primary Care and

Preventative Services

Expand Primary Care and Expand Primary Care and Preventative ServicesPreventative Services

• Health is better in areas where more primary care physicians

• People who receive care from a primary physician are healthier

• Major features of primary care are associated with better health

• “A greater emphasis on primary care can be expected to lower the costs of care [affordability], improve health through access to more appropriate services [right care], and reduce the inequities in the population’s health [equity].”

Source: Starfield, B., L. Shi, and J. Macinko. 2005. “Contributions of Primary Care to Health Systems and Health.” Milbank Quarterly 83(3):457-502.

Options for Expanding Primary Options for Expanding Primary Care and Preventative ServicesCare and Preventative Services

• Restructure payment and benefit design to emphasize primary and preventative care

• Promote primary care vs. specialty care

• Raise status of primary care providers

Expand Use of Interoperable Expand Use of Interoperable Health ITHealth IT

1. Achieve Universal Participation

2. Organize care and Information

Around the Patient

3.Expand Primary Care and

Preventative Services

4. Expand Use of Interoperable

Health Information Technology

Over 80% Medication Errors Prevented Over 80% Medication Errors Prevented with Computerized Order Entry Systemwith Computerized Order Entry System

Adapted with permission from D.W. Bates et . al. 1999. “The Impact of Computerized Physician Order Entry on Medication Error Prevention.” Journal of the American Medical Informatics Association 6(4):313-21.

26.6

51.2

142.0

74.0

0

20

40

60

80

100

120

140

160

Baseline(1992)

Period 1(1993)

Period 2(1995)

Period 3(1997)

Overall MedicationErrors (except misseddose)

1.7

7.6

7.3

1.1

0

1

2

3

4

5

6

7

8

Baseline(1992)

Period 1(1993)

Period 2(1995)

Period 3(1997)

Serious MedicationErrors (nonintercepted)

Options forOptions for Expanding Use of Expanding Use of Interoperable Health ITInteroperable Health IT

• Many activities underway in private and public sectors

• Possible roles for government include:– Provide incentives for providers to improve health care

performance– Pay for providers to acquire technology, especially those

in small, rural or safety-net institutions– Eliminate dysfunctional restrictions on market transactions– Use muscle as large purchaser to require uptake of HIT

Reward PerformanceReward Performance

1. Achieve Universal Participation

2. Organize care and Information

Around the Patient

3.Expand Primary Care and

Preventative Services

4. Expand Use of Interoperable

Health Information Technology

5. Reward Performance

Improvement in Doctors’ Cervical Cancer Screening Rates After Implementation of Quality Incentive Program

5.3

1.7

0

5

10

15

20

California Pacific Northwest

Source: M.B. Rosenthal et al. 2004. “Early Experience with Pay-for-Performance: From Concept to Practice,” JAMA 294(14): 1788-93.

Percent improvement in cervical cancer screening rates among physician groups

(Intervention group) (Control group)

Building Quality Into RIte CareBuilding Quality Into RIte CareHigher Quality and Improved Cost TrendsHigher Quality and Improved Cost Trends

• Quality targets and $ incentives

• Improved access, medical home

– One third reduction in hospital and ER

– Tripled primary care doctors

– Doubled clinic visits

• Significant improvements in prenatal care, birth spacing, lead paint, infant mortality, preventive care

Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003. Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005.

Cumulative Health Insurance Cost Trend

Comparison

0

20

40

60

80

100

120

140

160

RI Commercial Trend

RIte Care Trend

Percent

Pay for Performance ProgramsPay for Performance Programs• There are almost 90 pay-for-performance programs across the U.S.

– Provider driven (e.g., Pacificare)– Insurance driven (e.g., BC/BS in MA)– Employer driven (e.g., Bridges to Excellence – Verizon, GE, Ford,

Humana, P&G, and UPS)– Medicare

• 2003 Medicare Rx legislation demonstrations of Medicare physicians a per-beneficiary bonus if specified quality standards are met

– Medicaid• RIte Care will pay about 1% bonus on its capitation rate to

plans meeting 21 specified performance goals• 4 other states built performance-based incentives into

Medicaid contracts – UT, WI, IO, MA• Evaluation of impact still pending

Source: Leapfrog report for Commonwealth Fund; additional information available at http://www.leapfroggroup.org/

Options for Rewarding Options for Rewarding PerformancePerformance

• Assuring a “business-case” for investing in high performance

• Financial incentives

– Pay-for-Performance (P4P)

• California’s Integrated Healthcare Association (IHA) is the current benchmark for a statewide effort (www.iha.org)

– Tiered networks, co-pays

• Non-financial incentives

– Public reporting

• MHQP (Massachusetts Health Quality Partners); California (CalHospitalCompare.org)

– Recognition

Enhance Value and Quality of Enhance Value and Quality of CareCare

1. Achieve Universal Participation

2. Organize care and Information

Around the Patient

3.Expand Primary Care and

Preventative Services

4. Expand Use of Interoperable

Health Information Technology

5. Reward Performance

6. Enhance Value and

Quality of Care

Transitional Care ReducesTransitional Care ReducesRehospitalization for Heart Failure PatientsRehospitalization for Heart Failure Patients

61

48

0

20

40

60

80

100

162

104

0

50

100

150

200

$12,481

$7,636

$0

$4,000

$8,000

$12,000

$16,000

Percentage of patients who were rehospitalized or died

Number ofhospital readmissions

Average cost of care

Source: Medical records and patient interviews (N=239) (Naylor et al. 2004), S. Leathermanand D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005,The Commonwealth Fund. www.cmwf.org/usr_doc/MedicareChartbk.pdf.

Usual care group Intervention group

Resource use among congestive heart failure patients ages 65+ treated atsix Philadelphia hospitals during 1997–2001 who were randomly assignedto receive a three-month transitional care intervention or usual care

Options for Enhancing the Value Options for Enhancing the Value and Quality of Careand Quality of Care

• Development of programs to improve

– Preventive care; Acute care; Chronic care; End of life care

– Effectiveness; Safety; Efficiency

• Redesign of care structure; processes

• Evidence-based practice

– Including disease management programs

Promising State Strategies to Improve Quality Promising State Strategies to Improve Quality and Efficiencyand Efficiency

• Promote evidence-based medicine• Promote effective chronic care management• Promote transitional care post-hospital discharge• Encourage data transparency and reporting on

performance• Promote/practice value-based purchasing• Promote the use of health information technology• Promote wellness and healthy living• Encourage selection of medical home and improved

access to primary care and preventive services• Simplify and streamline public program eligibility

and re-determination

Encourage CollaborationEncourage Collaboration

1. Achieve Universal Participation

2. Organize care and Information

Around the Patient

3.Expand Primary Care and

Preventative Services

4. Expand Use of Interoperable

Health Information Technology

5. Reward Performance

6. Enhance Value and

Quality of Care

7. Encourage Collaboration

Developmental Screening Rates at Utah Practice Developmental Screening Rates at Utah Practice Sites Improve After Learning CollaborativeSites Improve After Learning Collaborative

0

20

40

60

80

Month

1

Month

2

Month

3

Month

4

Month

5

Month

6

Month

7

Source: Utah Pediatric Partnerships to Improve Healthcare Quality, 2005

Percent of children screened

Options forOptions for Enhancing Enhancing CollaborationCollaboration

• Promote public-private partnerships with employers for quality and efficiency initiatives

• Create pools for coverage and better information

• Reward learning collaboratives for delivery redesign

Health System Options for the Health System Options for the United StatesUnited States

“Unbounded Chaos” “Coordinated Private-Public”

“Central Control”

Consumers Doctors Health Care Organizations

Hospitals Purchasers

Issue for the U.S.: What would transform “unbounded chaos” into a bounded coordinated

public-private high performance system?

Who are the Players?Who are the Players?• General public• Employers• Insurers• Federal Government • Physicians• Health Educators• Hospitals• Other health care providers• Pharmaceutical companies• State Government• Accreditors

Fort Hunt U-15 Lacrosse Team

(Jesse Gauthier, #4)

**Are They a Team?

The First Necessary ConditionThe First Necessary Condition

• There needs to be a leader

• Teams have captains

• How can educators lead the way towards high performance?

Special Roles for EducatorsSpecial Roles for Educators

• Conduct research on best practices in primary care and prevention

• Learn and teach best practices to individuals and the public

• Establish community-based and school-based outreach centers/sites

• Support leaders and polices for expanding coverage

• Practice shared decision making• Adopt information technology

Visit the Fund at:http://www.cmwf.org

AcknowledgementsStephen C. Schoenbaum Executive Vice President for Programs

Karen DavisPresident

Ilana WeinbaumProgram Associate