the commonwealth fund karen davis president, the commonwealth fund centre for health services and...
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THE COMMONWEALTH
FUND
Karen DavisPresident, The Commonwealth Fund
Centre for Health Services and Policy Research Conference
March 4, [email protected]
www.commonwealthfund.org
Health System Performance: Challenges for the U.S. and Canada
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THE COMMONWEALTH
FUND
Goals for a High Performance Goals for a High Performance Health SystemHealth System
HIGH QUALITY CARE ACCESS AND EQUITY
FOR ALL
EFFICIENTCARE
SYSTEM AND WORKFORCE
INNOVATION AND IMPROVEMENT
LONG, HEALTHY,
AND PRODUCTIVE
LIVES
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THE COMMONWEALTH
FUND
US Scorecard: US Scorecard: Why Not the Best?Why Not the Best?
Commonwealth Fund Commission National ScorecardCommonwealth Fund Commission National Scorecard
69
71
67
51
71
66
0 100
Long, Healthy &Productive Lives
Quality
Access
Efficiency
Equity
OVERALL SCORE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 3
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THE COMMONWEALTH
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Mirror Mirror: US and Canada Fall BehindMirror Mirror: US and Canada Fall Behind
AUSTRALIA CANADA GERMANYNEW
ZEALANDUNITED
KINGDOMUNITEDSTATES
OVERALL RANKING (2007) 3.5 5 2 3.5 1 6
Quality Care 4 6 2.5 2.5 1 5
Right Care 5 6 3 4 2 1
Safe Care 4 5 1 3 2 6
Coordinated Care 3 6 4 2 1 5
Patient-Centered Care 3 6 2 1 4 5
Access 3 5 1 2 4 6
Efficiency 4 5 3 2 1 6
Equity 2 5 4 3 1 6
Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6
Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102
Country Rankings
1-2.66
2.67-4.33
4.33-6.0
* 2003 dataSource: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care , The Commonwealth Fund, May 2007
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THE COMMONWEALTH
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7681
88 8489 89
99 9788
97
109 106116 115 113
130134
128
115
65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110
0
50
100
150 1997/98 2002/03
Deaths per 100,000 population*
* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.See Technical Appendix for list of conditions considered amenable to health care in the analysis.Data: E. Nolte, London School of Hygiene and Tropical Medicine analysis of World Health Organization (WHO) mortality files.
Mortality Amenable to Health CareMortality Amenable to Health Care
LONG, HEALTHY & PRODUCTIVE LIVES
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5
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THE COMMONWEALTH
FUND
International Comparison of Spending on Health, 1980–International Comparison of Spending on Health, 1980–20052005
0
1000
2000
3000
4000
5000
6000
7000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data
0
2
4
6
8
10
12
14
16
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Average spending on healthper capita ($US PPP)
Total expenditures on healthas percent of GDP
6
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THE COMMONWEALTH
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Overall Views of the Health Care SystemOverall Views of the Health Care Systemin Seven Countries, 2007 and 1998in Seven Countries, 2007 and 1998
Percent reporting: AUS CAN GER NETH NZ UK US
Only Minor Changes Needed
2007 24 26 20 42 26 26 16
1998 19 20 * * 9 25 17
Fundamental Changes Needed
2007 55 60 51 49 56 57 48
1998 49 56 * * 57 58 46
Rebuild Completely
2007 18 12 27 9 17 15 34
1998 30 23 * * 32 14 33
* Germany and the Netherlands did not participate in the 1998 survey.Sources: 1998 and 2007 Commonwealth Fund International Health Policy Surveys
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THE COMMONWEALTH
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Improving AccessImproving Access
• Remove financial barriers to care• Enroll patients in a patient-centered primary care
“home”– Standards for a primary care home
• Accessibility• Care coordination• Prevention and health promotion• Chronic disease management• Patient-centered care
– Monitoring performance– Aligning financial incentives
• Organized system of “off hours” care coordinated with regular source of care
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THE COMMONWEALTH
FUND
Fewer Canadians Face Cost-Related Access Fewer Canadians Face Cost-Related Access Problems Than AmericansProblems Than Americans
Percent in past year due to cost:
AUS CAN GER NETH NZ UK US
Did not fill prescription or skipped doses
13 8 11 2 10 5 23
Had a medical problem but did not visit doctor
13 4 12 1 19 2 25
Skipped test, treatment or follow-up
17 5 8 2 13 3 23
Percent who said yes to at least one of the above
26 12 21 5 25 8 37
Source: 2007 Commonwealth Fund International Health Policy Survey. (Schoen et al. Health Affairs 10/31/07)
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THE COMMONWEALTH
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Access to Doctor When SickAccess to Doctor When Sickor Need Medical Attentionor Need Medical Attention
42
10
55
20
49
5 4
41
12
223030
20
53
0
25
50
75
Same-day appointment Wait of 6 days or more
Percent
AUS GER NETH NZ UK CAN US
Source: 2007 Commonwealth Fund International Health Policy Survey
AUS GER NETH NZ UK CAN US
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THE COMMONWEALTH
FUND
Over One-Third of Canadians and Americans Report Over One-Third of Canadians and Americans Report Difficulty Getting Care on Nights, Weekends, Holidays Difficulty Getting Care on Nights, Weekends, Holidays
Without Going to the Emergency RoomWithout Going to the Emergency Room
3525
1220
2938 38
25
3428
26
28 2829
0
25
50
75
AUS GER NETH NZ UK CAN US
Very Difficult Somewhat Difficult
Percent reported very or somewhat difficult
Source: 2007 Commonwealth Fund International Health Policy Survey
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THE COMMONWEALTH
FUND
Primary Care Doctors in Canada and U.S. Less Likely to Primary Care Doctors in Canada and U.S. Less Likely to Have Arrangement for Patients’ After-Hours Care to See Have Arrangement for Patients’ After-Hours Care to See
Nurse/DoctorNurse/Doctor
4047
7681
879095
0
25
50
75
100
NETH NZ UK AUS GER CAN US
Percent
Source 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. (Schoen et al. “On the Front Lines of Care…” Health Affairs, Nov. 2, 2006.
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THE COMMONWEALTH
FUND
More Canadians and Americans Visited the Emergency More Canadians and Americans Visited the Emergency Room For Condition Doctor Could Have Treated Than Room For Condition Doctor Could Have Treated Than
Other CountriesOther Countries
33
39
2118
28 28
36
5 69
1116
8
15
0
25
50
AUS CAN GER NETH NZ UK US
Any visits
Visited ER for condition doctor could have treated if available
Source: 2007 Commonwealth Fund International Health Policy Survey
Percent
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THE COMMONWEALTH
FUND
Only Half of Adults in Canada and U.S. Have a Only Half of Adults in Canada and U.S. Have a Medical Home Medical Home
59
45 47
61
47 48 50
0
25
50
75
AUS GER NET NZ UK CAN US
Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.Source: 2007 Commonwealth Fund International Health Policy Survey
Percent
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THE COMMONWEALTH
FUND
Canadians with Chronic Condition Less Likely to Receive a Canadians with Chronic Condition Less Likely to Receive a Reminder for Preventive Care, Even With a Medical HomeReminder for Preventive Care, Even With a Medical Home
50
67 63
51
64
49
76
63
29
5044
5448
35
0
25
50
75
100
AUS GER NETH NZ UK CAN US
Has medical home No medical home
Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.Source: 2007 Commonwealth Fund International Health Policy Survey
Percent with reminder
Base: Adults with a chronic condition
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THE COMMONWEALTH
FUND
45
24
3639
3438
55
47
28253027
19
32
0
25
50
75
AUS GER NETH NZ UK CAN US
Has medical home No medical home
Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.Source: 2007 Commonwealth Fund International Health Policy Survey
Percent with care plan
Base: Adults with a chronic condition
Less Than One in Three Canadians Without a Medical Less Than One in Three Canadians Without a Medical Home and a Chronic Condition Receive a Care Plan to Home and a Chronic Condition Receive a Care Plan to
Manage Condition at HomeManage Condition at Home
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THE COMMONWEALTH
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Engaging Patients and Managing CareEngaging Patients and Managing CareChronic Care Model and Medical Home Fit Chronic Care Model and Medical Home Fit
TogetherTogether
• Chronic care model requires a team, patient-centered approach, IT support
• Country initiatives around disease management or frail elderly have elements related to building medical homes
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THE COMMONWEALTH
FUND
Percent any medical, medication, or lab error
Canadian and American Patients Report High Rates of Any Canadian and American Patients Report High Rates of Any Medical, Medication, or Lab ErrorMedical, Medication, or Lab Error
18
11
1715
11
172119
22
3026
2934
30
0
25
50
AUS GER NETH NZ UK CAN US
Has medical home No medical home
Base: Adults with chronic condition
Note: Errors include medical mistake, wrong medication/dose, or lab/diagnostic errors. Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey. (Schoen et al. Health Affairs 10/31/07)
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THE COMMONWEALTH
FUND
Canadian and American Patients with a Medical Home Canadian and American Patients with a Medical Home More Likely to Receive Quality More Likely to Receive Quality
Care from DoctorCare from Doctor
87
6570
82 868889
5157
4959
4740
60
0
25
50
75
100
AUS GER NETH NZ UK CAN US
Has medical home No medical homePercent rated care received “excellent” or “very good”
Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.Source: 2007 Commonwealth Fund International Health Policy Survey
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THE COMMONWEALTH
FUND
Physicians in Canada and U.S. Less Likely to Participate in Physicians in Canada and U.S. Less Likely to Participate in Activities to Improve Quality of Care Activities to Improve Quality of Care
AUS CAN GER NETH NZ UK US
Percent in past two years who:
Participated in collaborative QI efforts
58 48 76 70 78 58 49
Conducted clinical audit of patient care
76 45 69 46 82 96 70
Percent reporting their practice:
Sets formal targets for clinical performance
26 27 70 35 41 70 50
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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THE COMMONWEALTH
FUND
Coordination Problems: Medical Records Not Available Coordination Problems: Medical Records Not Available During Visit or Duplicative TestsDuring Visit or Duplicative Tests
Percent reported in past two years:
AUS CAN GER NETH NZ UK US
Test results or records not available at time of appointment
11 11 8 7 9 10 15
Duplicate tests: doctor ordered test that had already been done
10 5 15 4 6 5 14
Percent with either coordination problem
18 15 19 9 12 13 23
Source: 2007 Commonwealth Fund International Health Policy Survey
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THE COMMONWEALTH
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95
7972
58
43 41
30
0
25
50
75
100
UK NZ AUS NETH GER CAN US
Percent of physicians reporting any financial incentive for quality of care*
* Receive or have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activities.
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Physicians in Canada and U.S. Less Physicians in Canada and U.S. Less Likely to Receive Incentives for Likely to Receive Incentives for
QualityQuality
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THE COMMONWEALTH
FUND
Where are the U.S. and Canada on IT?Where are the U.S. and Canada on IT?
9289
79
42
2823
98
0
25
50
75
100
NET NZ UK AUS GER US CAN
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians in Seven Nations: Australia, Canada, Germany, Netherlands, New Zealand, UK, and US.
8783
72
59
32
19
8
0
25
50
75
100
NZ UK AUS NET GER US CAN
Percent reporting 7 or more out of 14 functions*
*Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care.
Percent reporting EMR
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THE COMMONWEALTH
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2340
8093 87 91
6 6
10
3128
33
102
0
25
50
75
100
CAN US GER AUS NET NZ UK
Y es, using a manual systemY es, using a computerized system
Doctors Reporting Routinely Receiving Alerts Doctors Reporting Routinely Receiving Alerts about Potential Problem with Drug about Potential Problem with Drug
Dose/InteractionDose/Interaction
Percent of physicians
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
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THE COMMONWEALTH
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Denmark Leads the Way In IT and Patient-centered Denmark Leads the Way In IT and Patient-centered Primary Care 2006: An Example of High PerformancePrimary Care 2006: An Example of High Performance
• Highest public satisfaction with health system among European countries
• Blended primary care payment system: fee for service and medical home monthly fee per patient
• Organized off-hours service
– Physicians staff phone banks nights and weekends with computerized access to patient information; paid for telephone consultations
– Physicians staff evening and weekend clinics, and
– Off-hours service physicians do home visits
• Health information technology and information exchange
– 98% of primary care physicians totally electronic health records and e-prescribing
– Paid for e-mail with patients
– All prescriptions, lab and imaging tests, specialist consult reports, hospital discharge letters flow through a single electronic portal accessible to patients, physicians, and home health nurses
– Specialist payment depends upon filing information in the electronic portal
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THE COMMONWEALTH
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Take Away MessagesTake Away Messages
• Country patterns reflect underlying strategic policy choices
– Universal coverage matters
– Having an integrated health care “system” matters
– National leadership on health policy matters
• Regardless of system characteristics, having a “Medical Home” that is accessible and coordinates care improves patient experiences
– Patient safety
– Coordination with specialists/across sites of care
– Patient-centeredness and satisfaction
– Managing Chronically Ill patients
– Efficiency: duplication and delays
– After-hours care arrangements
• Health information technology has significant potential:– To enhance data availability on which to benchmark and improve
performance– To improve quality by supporting providers and patients– To improve care coordination across providers of care– To improve accessibility of care– To improve physician satisfaction with practice
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THE COMMONWEALTH
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ConclusionsConclusions• No country systematically leads in performance
• Variations in health system performance offer opportunities for cross-national learning
• Managing patients with complex, chronic illnesses is a shared challenge
• Primary Care “redesign” and Workforce Strategy are critical to improving health system performance
• Making rapid progress requires:– Learning from best practices within country and across countries– Aligning incentives for high value care– Accountable coordinated care for all patients– Implementation of electronic information systems – Accountable leadership
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Thank You!Thank You!Stephen C. Schoenbaum, M.D., Executive Vice President and Executive Director, Commission on a High Performance Health System, [email protected]
Katherine Shea, Research Associate
Cathy Schoen, Senior Vice President for Research and Evaluation [email protected]
Sign up for Commonwealth Fund e-alerts – http://www.commonwealthfund.org
Robin Osborn, Vice President and Director, International Program in Health Policy and Practice [email protected]