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
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