why not the best? towards a high performance health system cathy schoen senior vice president, the...
TRANSCRIPT
Why Not the Best? Towards A High Performance Health System
Cathy Schoen
Senior Vice President, The Commonwealth Fund
Alaska Health Summit
December 6, 2006
2
Presentation Overview
• High Performance Health System– The Commonwealth Fund Commission on a High
Performance Health System– What Constitutes A High Performance System?
• Where Are We Now? Performance and Achievable Benchmarks
• Levers for Change to Improve Performance: States in Action
• Moving Forward
THE COMMONWEALTH
FUND
3
The Commonwealth Fund Commission on a High Performance Health System
Objective:
• 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, gaps in insurance coverage, race/ethnicity, health, or age
Commission Members, including James J. Mongan, MD, Chairman; Alan Weil, JD; and others
4
Key Dimensions of a High Performance Health System
EFFICIENT CARE
HIGH QUALITY CARE
EQUITY
ACCESS and Affordability
LONG,HEALTHY, ANDPRODUCTIVE
LIVES
SYSTEM INNOVATION AND IMPROVEMENT
THE COMMONWEALTH
FUND
5
Achieving a High Performance Health System Requires:
• Committing to a clear, coherent strategy and establishing a process to implement and refine that strategy
• Enabling universal participation • Delivering care through models that emphasize
coordination and integration• Implementing payment systems that support and
encourage high quality, efficient, and accessible care• Developing information systems and
establishing/tracking metrics for health outcomes, quality, access, and efficiency
THE COMMONWEALTH
FUND
6
National and State Performance:National and State Performance:Where We Are Now and Achievable Where We Are Now and Achievable
BenchmarksBenchmarks
THE COMMONWEALTH
FUND
7
Scorecard on U.S. Health System• National scorecard including spanning core domains of
performance– Benchmarks based on achieved performance. Top states,
regions, providers or countries– Overall score of 66 reflects pervasive shortfalls
• The U.S. falls far short on each of the core goals for health
system performance – Wide gaps and variation within U.S.
• The consequence is needlessly lost lives, wasted health care expenditures, and lower economic productivity
• Given that the U.S. spends more than any other country, we should expect to lead on access, quality and efficiency– High value: benchmarks provide targets for improvement
• With cost and coverage moving in the wrong direction, action to achieve better performance is of great urgency THE
COMMONWEALTH FUND
8
Mortality Amenable to Health Care
97 97 99106 107 109 109
115 115
129 130 132
7584 88 88 88
81
92
0
50
100
150
Deaths per 100,000 population*
110
7884
90
103
119
134
Percentiles
Internationalvariation, 1998
State variation,2002
* 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: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003);State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology.
Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
LONG, HEALTHY & PRODUCTIVE LIVES 8
9
7.0
5.65.3
6.0
7.1
8.1
9.1
Infant Mortality Rate, 2002
* 2001.Data: International estimates—OECD Health Data 2005;State estimates—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2005a).
2.2
3.0 3.03.3 3.5
4.1 4.1 4.1 4.2 4.2 4.4 4.4 4.5 4.55.0 5.0 5.0 5.0 5.1 5.2 5.4 5.6
7.0
0
5
10
Infant deaths per 1,000 live births
Percentiles
International variation State variation
LONG, HEALTHY & PRODUCTIVE LIVES
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
9
10
States Vary In Quality of Care – Medicare IndicatorsAlaska Ranks in Third Quartile on Provision of Appropriate Care
First
Third
Fourth
Source: S.F. Jencks, E.D. Huff, and T. Cuerdon, “Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998–1999 to 2000–2001,” Journal of the American Medical Association 289, no. 3 (Jan. 15, 2003): 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
AK
MD
MEVT
NH
MA
RI
CT
DE
DCCO
GAMS
OK
NJ
SD
Quartile Rank
Note: State ranking based on 22 Medicare performance measures.
2000–2001
THE COMMONWEALTH
FUND
11
Receipt of Recommended Screening and Preventive Care for Adults, by Family Income and Insurance Status, 2002
31
46
52
39
48
56
49
0 50 100
Uninsured All Year
Uninsured Part Year
Insured All Year
<200% of Poverty
200-399% of Poverty
400%+ of Poverty
National
Percent of adults (ages 18+ yrs) who received all recommended screening and preventive care within a specific time frame given their age and sex*
*Recommended care includes: blood pressure, cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.Data: Columbia University analysis of 2002 Medical Expenditure Panel SurveySOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: RIGHT CARE
12
Preventive Care Visits for Children, 2003
35
63
70
58
62
48
73
55
59
48
49
0 50 100
Uninsured
Private insurance
<100% of poverty
400% + of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
Alaska
U.S. average
Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE 12
Percent of children (ages <18) received BOTH a medical and dental preventive care visit in past year
13
Immunizations for Young Children, 2003
75
87
79
83
89
80
79
77
77
73
71
0 50 100
<100% of poverty
400%+ of poverty
AI/AN
Asian/PI
Hispanic
Black
White
Bottom 10% states
Top 10% states
Alaska
U.S. average
* Recommended vaccines include: 4 doses of diphtheria-tetanus-pertussis (DTP), 3+ doses of polio, 1+ dose of measles-mumps-rubella, 3+doses of Haemophilus influenzae type B, and 3+ doses of hepatitis B vaccine.PI = Pacific Islander; AI/AN = American Indian or Alaskan Native. Data: National Immunization Survey (AHRQ 2005a, 2005b).
Percent of children (ages 19–35 months) who received all recommended doses of five key vaccines*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE 13
14
Heart Failure Patients Given Written Instructions or Educational Materials When Discharged, by Hospitals and States, 2004
50
37
6460
49
3326
87
9
0
50
100
NationalAverage
Alaska Top 10% Top 25% Median Bottom25%
Bottom10%
90th %ile 10th %ile
Percent of heart failure patients discharged home with written instructions or educational material*
* Discharge instructions must address all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.Data: National and hospital estimates—A. Jha and A. Epstein, Harvard University analysis of data from Hospital Quality Alliance national reporting system; State estimates—Retrieved from Hospital Compare database at http://www.hospitalcompare.hhs.gov.
HospitalsStates
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE 14
15
* Child had 1+ preventive visit in past year; access to specialty care; personal doctor/nurse who usually/always spent enough time and communicated clearly, provided telephone advice or urgent care and followed up after the child’s specialty care visits.Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).
23
53
58
39
53
36
60
38
46
30
31
0 50 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
Alaska
U.S. average
Children with a Medical Home, 2003
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
Percent of children who have a personal doctor or nurse and receive care that is accessible, comprehensive, culturally sensitive, and coordinated*
15
16
Nursing Homes: Hospital Admission and Readmission RatesAmong Nursing Home Residents, per State, 2000
16
89
12
19
21
0
10
20
30
Median Beststate
10th%ile
25th%ile
75th%ile
90th%ile
Percent
12
78
10
13
16
0
10
20
30
Median Beststate
10th%ile
25th%ile
75th%ile
90th%ile
Hospitalization rates Re-hospitalization rate (within 3 months of
nursing home admission)
Data: V. Mor, Brown University analysis of Medicare enrollment data and Part A claims data for all Medicare beneficiaries who entered a nursing home and had a Minimum Data Set assessment during 2000.
Percent
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE 16
17
Hospital-Standardized Mortality Ratios, 2000–2002
8593 94 97 100 103 106 106
112118
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10
Ratio of actual to expected deaths in each decile (x 100)
Decile of hospitals ranked by actual to expected deaths ratios
See Technical Appendix for methodology.Data: B. Jarman analysis of Medicare discharges from 2000 to 2002 for conditions leading to 80 percent of all hospital deaths.
Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors. Medicare national average for 2000 = 100
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE 17
18
13 13
89
16
19
24
1415
2223
18
0
15
30
High-risk residents
Pressure Sores Among High-Risk and Short-Stay Residentsin Nursing Facilities
Percent of nursing home residents with pressure sores
AI/AN = American Indian or Alaskan Native.Data: Nursing Home Minimum Data Set (AHRQ 2005a, 2005b).
Short-stay residents
High-risk residents
Short-stay residents
White 13% 21%
Black 17 26
Hispanic 15 25
Asian 12 22
AI/AN 17 23
State distribution, 2004 By race/ethnicity, 2003
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE 18
19
Percent of Uninsured Adults Ages 18–64 is IncreasingAlaska’s Rate Average 22 to 23%
Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute.
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
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
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DE
DC
HI
CO
GAMS
OK
NJ
SD
19%–22.9%
Less than 14%
14%–18.9%
23% or more
1999–2000 2004–2005
MA
RI
CT
VTNH
MD
NH
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: UNIVERSAL PARTICIPATION 19
20
States Average Employer Health Insurance Premiums, 2004 -- Employee-only Annual
3,8823,705
3,1193,3423,4143,534
3,7813,8584,116
4,379
$0
$1,000
$2,000
$3,000
$4,000
$5,000
A laska Maine New
J ersey
New Y ork T exas U.S .
average
C ali fornia A labama North
Dakota
Hawaii
Source: AHRQ, 2004 MEPS-IC; Retrieved from MEPS State-level Insurance Component Summary Tables at http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables_search.jsp?component=2&subcomponent=2
Dollars
THE COMMONWEALTH
FUND
21
International Comparison of Spending on Health, 1980–2004
0
1000
2000
3000
4000
5000
6000
7000 United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Data: OECD Health Data 2005 and 2006.
0
2
4
6
8
10
12
14
16
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Average spending on healthper capita ($US PPP)
Total expenditures on healthas percent of GDP
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY 21
22
Ambulatory Care Sensitive (Potentially Preventable)Hospital Admissions for Select Conditions, 2002
498
241188
258
13774
631
299 297
0
100
200
300
400
500
600
700
Congestive heart failure Diabetes Pediatric asthma
National average Top 10% states Bottom 10% states
Adjusted rate per 100,000 population
* Combines four diabetes admission measures: uncontrolled, short-term complications, long-term complications, and lower extremity amputations. Data: National estimates—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; State estimates—State Inpatient Databases; not all states participate in HCUP (AHRQ 2005a).
*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY 22
23
Medicare Hospital 30-Day Readmission Rates and Associated Costs, by Hospital Referral Regions, 2003
18
1614
16
2022
0
5
10
15
20
25
30
Nationalmean
Alaska 10th 25th 75th 90th
35
2724
30
34
45
0
10
20
30
40
50
Nationalmean
Alaska 1 2 3 4
Rate of hospital readmission within 30 days
Readmission reimbursement as percent of total reimbursement for all admissions
Quartile of regions rankedby readmission rates
Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2003 Medicare Standard Analytical Files (SAF) 5% Inpatient Data.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
Percentiles
23
24
0.80
0.90
1.00
1.10
1.20
$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000
Relative Resource Use**
Qu
alit
y o
f C
are*
(1
Yea
r S
urv
ival
In
dex
, M
edia
n =
70%
)
Quality and Costs of Care for Medicare Patients Hospitalized for Heart Attacks, Colon Cancer and Hip Fracture, by Hospital
Referral Regions, 2000-2002
Median Relative Resource Use = $25,995
* Indexed to risk-adjusted 1 year survival rate (median = 0.70).** Risk-adjusted spending on hospital and physician services using standardized national prices.Data: E. Fisher and D. Staiger, Dartmouth College analysis of data from a 20% national sample of Medicare beneficiaries.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY 24
25
Percent of National Health Expenditures Spent on Insurance Administration/Overhead, 2003
*Includes claims administration, underwriting, marketing, profits and other administrative costs. Data: OECD Health Data 2005SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
Net costs of health administration and health insurance as percent of national health expenditures
1.9 2.1 2.12.6
3.34.0 4.1 4.2
4.8
5.6
7.3
0
2
4
6
8
France
Finla
nd
Japan
Canad
a
Unite
d Kin
gdom
Nether
lands
Austri
a
Austra
lia
Switzer
land
Germ
any
Unite
d Sta
tes
a
a2002 b1999
b
c2001
c *
EFFICIENCY
26
Physicians’ Use of Electronic Medical Records, U.S. Compared to Other Countries, 2000/2001
90 88
6258 56 55 52
4842
3730 29 28
25
17 1714
9 6 5
0
50
100
Sweden
Netherl
ands
Denmark
United K
ingdom
Finland
Austria
New Zealand*
Germany
Belgium
Italy
Luxembourg
EU Average
Ireland
Australia
*
Greec
e
United States*
Canada*
Spain
France
Portugal
Percent of physicians
*2000Data: 2001 European Union EuroBarometer and 2000 Commonwealth Fund I Survey of Physicians (Harris Interactive 2002)SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
27
Receipt of All Three Recommended Services for Diabetics, 2002
45
55
54
46
50
61
55
53
54
47
24
38
0 50 100
Rural
Urban
Uninsured
Private
<100% of poverty
100% –199% of poverty
200% –399% of poverty
400% + of poverty
Hispanic
Black
White
Total
Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year
* Insurance for people ages 18–64.** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants.Data: 2002 Medical Expenditure Panel Survey (AHRQ 2005a).
*
**
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: THE RIGHT CARE 27
28Keys to Transforming the U.S. Health Care
System1. Guarantee affordable health insurance coverage2. Implement major quality and safety improvements3. Develop more organized delivery systems that emphasize
patient-centered primary and preventive care 4. Increase transparency and reporting on quality and costs5. Expand the use of interoperable information technology6. Reward performance for quality and efficiency 7. Encourage public-private collaboration to simplify and achieve
more effective change
THE COMMONWEALTH
FUND
29
1. Guarantee Affordable Health Insurance Coverage
THE COMMONWEALTH
FUND
Guarantee Affordable Health Insurance Coverage
30
Massachusetts Health Plan
• MassHealth expansion for children up to 300% FPL; adults up to 100% poverty
• Individual mandate, with affordability provision; subsidies between 100% and 300% of poverty
• Employer mandatory offer, employee mandatory take-up
• Employer assessment ($295 if employer doesn’t provide health insurance)
• Connector to organize affordable insurance offerings through a group pool
Source: John Holahan, “The Basics of Massachusetts Health Reform,” Presentation to United Hospital Fund, April 2006.
THE COMMONWEALTH
FUND
31
Maine’s Dirigo Health: Knitting Together Public, Private and Employer Insurance
• New insurance product; sliding scale deductibles and premiums below 300% poverty
• Employers pay fee covering 60% of worker premium
• Began Jan 2005; Enrollment 14,700 as of 4/30/06
• Combined with expanded public
* After discount and employer payment (for illustrative purposes only).
300600
8881188
1488
1250
0
1000
750
500
250
0$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
MaineCare <150% <200% <250% <300% >300%
Deduc tible amountEmployee share of annual premium
Annual expenditures on deductible and premium
$550
$0
$1,100
$1,638
$2,188
$2,738
THE COMMONWEALTH
FUND
32
Vermont Health Care Affordability Act Enacted May 2006
• Coverage expansion– Catamount Health Plans
• Targets those w/o access to work-based coverage • Premium subsidies based on sliding scale up to 300%
FPL • Comprehensive benefit package including primary,
chronic, acute care & other services • No patient cost-sharing for preventive or chronic care• Builds upon Wagner’s Chronic Care Model
• Financing– Employer assessment– Increase in tobacco taxes– Federal matching funds from Medicaid waiver
• Quality improvement initiatives– Public-private collaboration– Collection of health care data from all payers
• Rules to publicly report price & quality informationTHE
COMMONWEALTH FUND
33
Illinois All-Kids
• Effective July 1, 2006• Available to any child uninsured for 6 months or more• Cost to family determined on a sliding scale• Linked to other public programs - FamilyCare & KidCare • Federal and state funds
– Children <200% of FPL covered by federal funds– Children 200%+ of FPL funded by state savings from
Medicaid Primary Care Case Management Program • All-Kids Training Tour
– Public outreach program to highlight new and expanded healthcare programs
THE COMMONWEALTH
FUND
34
New Jersey Raises Age of Dependent Status for Health Insurance
• As of 5/2006, NJ requires all state insurers to raise dependent age limit to 30
– Highest age limit in country – Covers uninsured, unmarried
adults with no dependents who are NJ residents or FT students
– Premium capped at 102% of amount paid for dependent’s coverage prior to aging out
• 200,000 young adults expected to receive coverage
11.2 11.812.7 13.4 13.7
0
5
10
15
2000 2001 2002 2003 2004
Source: S.R. Collins, C. Schoen, J.L. Kriss, M.M. Doty, B. Mahato, “Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help,” Commonwealth Fund issue brief, May 2006. (Analysis of the March 2001–2005 Current Population Surveys)
Millions uninsured, adults ages 19–29
THE COMMONWEALTH
FUND
35
Implement Major Quality and Safety Improvements
2. Implement Major Quality and Safety Improvements
1. Guarantee Affordable Health Insurance Coverage
THE COMMONWEALTH
FUND
36
Rhode Island:Five-Point Strategy
1. Creating affordable plans for small businesses & individuals2. Increasing wellness programs 3. Investing in health care technology 4. Developing centers of excellence 5. Leveraging the state’s purchasing power
• RI Quality Institute – Non-profit coalition -- hospitals, providers, insurers, consumers,
business, academia & government– Partnered with “SureScripts” to implement state-wide electronic
connectivity between all retail pharmacies and prescribers in the state
• Health Information Exchange Initiative– Statewide public/private effort– AHRQ contract 5 yr/ $5M– Connecting information from physicians, hospitals, labs,
imaging & other community providersTHE
COMMONWEALTH FUND
37
Work Towards Coordinated and Patient-Centered Delivery of Care With A Focus on
Primary Care3. Emphasize Patient-
Centered Primary, and Preventive
Care
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
THE COMMONWEALTH
FUND
38
Importance of Primary Care• US has fewer primary care physicians
per capita, no designated medical home, higher out-of-pocket costs, better financial rewards for specialty care
• Better access to primary care lowers total cost, improves outcomes– Starfield et al, Milbank Quarterly
2005– Fisher analysis of Medicare
expenditures and patient outcomes• New primary care payment models
need to be tested• Health plans should exempt preventive
and primary care from deductibles, and
• Encourage enrollees to designate medical home
THE COMMONWEALTH
FUND
39
Utah’s Primary Care Network Section 1115 Medicaid Waiver
• Targets uninsured adults (19–54) with family income less than 150% FPL
• Provides primary care and preventive care services– Physician office visits– Immunizations– Emergency care– Lab, X-ray, medical equipment & supplies– Basic dental care– Hearing & vision screening– Prescription drugs
• Hospitals provide $10 million in charity care for PCN participants
THE COMMONWEALTH
FUND
40
Helping Patients Become Informed and Active Partners in Their Care
• www.howsyourhealth.org - Online surveys of patient experiences with feedback to community groups and physicians
• Primary Care Development Corporation New York – advanced access collaborative
• Shared decision-making
• Resident-centered care in nursing homes
• Family-centered care in Healthy Steps & ABCD
THE COMMONWEALTH
FUND
41
Center for Shared Decision-Making Dartmouth-Hitchcock Medical Center
• Provides tools to help patients understand trade-offs of medical vs. surgical treatment given their preferences
• Assist with health care decisions (e.g., videotapes, booklets, websites)
• Provides follow-up counseling with skilled staff
• Results in lower rates of invasive procedures, such as low-back surgery
Kate Clay, BA, MSN, Program Director
THE COMMONWEALTH
FUND
42
7063 60
93 91100
7974 70
6152 49
0
50
100
Staff managed pain well Staff responded when needed help Staff explained medicines and side effects
Average Best hospital 90th % ile hospitals 10th % ile hospitals
Patient-Centered Hospital Care: Staff Managed Pain, RespondedWhen Needed Help, and Explained Medicines, by Hospitals, 2005
Percent of patients reporting “always”
* Patient’s pain was well controlled and hospital staff did everything to help with pain.** Patient got help as soon as wanted after patient pressed call button and in getting to the bathroom/using bedpan.*** Hospital staff told patient what medicine was for and described possible side effects in a way that patient could understand.Data: CAHPS Hospital Survey results for 254 hospitals submitting data in 2005. National CAHPS Benchmarking Database.
* *****
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: PATIENT-CENTERED, TIMELY CARE 42
43Transitional Care ReducesRehospitalization 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
44
Increase Transparency and Reporting on Quality and Costs
4. Increase Transparency and Reporting on Quality and Costs
3. Emphasize Primary,
Preventive, and Patient-Centered
Care2. Implement Major Quality and Safety Improvements
1. Guarantee Affordable Health Insurance Coverage
45
Wisconsin
• Wisconsin Collaborative for Healthcare Quality
– Voluntary consortium formed in 2003 -- physician groups, hospitals, health plans, employers & labor
– Develops & publicly reports comparative performance information on physician practices, hospitals & health plans
– Includes measures assessing ambulatory care, IT capacity, patient satisfaction & access
• Wisconsin Health Information Organization
– Coalition formed in 2005 to create a centralized health data repository based on voluntary sharing of private health insurance claims, including pharmacy & laboratory data
– Wisconsin Dept of Health & Family Services and Dept of Employee Trust Funds will add data on costs of publicly paid health care through Medicaid THE
COMMONWEALTH FUND
46
Expand the Use of Interoperable Information Technology
5. Expand the Use of Interoperable Information Technology
4. Increase Transparency and Reporting on Quality and Costs
3. Emphasize Primary,
Preventive, and Patient-Centered
Care2. Implement Major Quality and Safety Improvements
1. Guarantee Affordable Health Insurance Coverage
47Primary Care Doctors Use of Electronic Patient
Medical Records, 2006
79
23
42
92 89
28
98
0
25
50
75
100
AUS CAN GER NET NZ UK US
Percent
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
THE COMMONWEALTH
FUND
48
Value of Electronic Medical Records and Information Systems
• Reduce duplicate tests• Reduce hospital admissions with information
accessible to ER• Improve patient care• Decision support for physicians and patients• Facilitate “referrals”, secure transfer of
responsibility• Reduce medical errors• Better management of chronic conditions
and care coordination– Registries– Performance information– Reminder and alerts– Facilitated by interoperability
• Saves physician and staff time on paperwork; redirects to patients
THE COMMONWEALTH
FUND
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Information Exchange:States In Action
• Rhode Island Quality Institute Information Exchange – Provide access to patient data (as permitted) to all providers initially
through secure web-based portal – future integration into EHRs– Create the ability to aggregate and utilize data for public health
purposes (e.g., population-based analysis, biosurveillance)
• MidSouth e-health Alliance: Memphis, TN– State-wide data exchange with initial focus on EDs
• Utah Health Information Network– Secure exchange of health care data using standardized transactions
through a single portal
• New York State Health Information Technology (HIT) initiative– Under the Health Care Efficiency and Affordability Law for New Yorkers,
$52.9 million awarded to 26 regional health networks to expand technology in NY health care system and support clinical data exchange; Commonwealth Fund-supported evaluation underway
Source: Evolution of State Health Information Exchange, AHRQ, Publication No. 06-0057, January 2006.
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Reward Performance for Quality and Efficiency
6. Reward Performance for Quality and Efficiency
4. Increase Transparency and Reporting on Quality and Costs
3. Emphasize Primary,
Preventive, and Patient-Centered
Care2. Implement Major Quality and Safety Improvements
1. Guarantee Affordable Health Insurance Coverage
5. Expand the Use of Interoperable Information Technology
51
Building Quality Into RIte CareHigher 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
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New York State Medicaid Pay-for-Performance
• 1997 — NYS began transition to mandatory statewide Medicaid managed care. Currently > 2.5 million enrollees (including Family Health Plus)
• 2002 — NYS DOH incorporated quality incentive into computation of Medicaid managed care capitation rates
– Incentive tied to performance on 10 quality of care measures and 5 consumer satisfaction measures
– Initial incentive up to an additional 1% of monthly premium; as of April 2005, maximum incentive increased to 3%
• 2005 — incentive payments totaled $40 million
• Commonwealth Fund supporting Dr. Robert Berenson (Urban Institute) to evaluate impact of quality incentive program — qualitative analysis (interviews/site visits of participating plans) and quantitative analysis of measures
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Medicare Physician Group Practice Demonstration
• The Everett Clinic (WA)• Deaconess Billings Clinic• Park Nicollet Health Services
(MN)• Marshfield Clinic (WI)• St. John’s Health System (MO)
Source: “Medicare Physician Group Practice Demonstration,” www.cms.gov, January 31, 2005.
• Univ. of Michigan Faculty Group Practice
• Geisinger Health System (PA)• Forsyth Medical (NC)• Middlesex Health (CN)• Dartmouth-Hitchcock Clinic
• 10 physician group practices
• 3-year project, began April 2005
• Bonus pool based on savings relative to local area
• Practices expected to save 2%, keep up to 80% of additional savings
• Actual bonuses depend on savings and quality targets
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14.813.6 13.1
11.6
15.4
0
5
10
15
20
Bottom
quality
quartile
26–50% 51–75% 76–90% Top quality
dec ile
Medicare Premier Hospital Demonstration: Higher Quality Hospitals Have Fewer Readmissions
Readmission Rates by Pneumonia Quality Ranking (Percent)
© 2005 Premier, Inc.Source: Stephanie Alexander, “CMS/Premier Hospital Quality Incentive Demonstration Project:1st Year Results,” Presentation at IOM P4P Subcommittee Meeting, November 30, 2005
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55California Integrated HealthCare Association
Pay for Performance Initiative
2003 2004 2005
Clinical 50% 40% 50%
Patient Experience 40% 40% 30%
IT Investment 10% 20% 20%
Patient Experience domain:
•Communication with doctor
•Overall ratings of care
•Care coordination
•Specialty care
•Timely access to care
Source: Tom Williams, “California Pay for Performance (P4P): A Case Study.”
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56Encourage Public-Private Collaborationto Achieve Simplification,
More Effective Change
7. Encourage Public-Private Collaboration
4. Increase Transparency and Reporting on Quality and Costs
3. Emphasize Primary,
Preventive, and Patient-Centered
Care2. Implement Major Quality and Safety Improvements
1. Guarantee Affordable Health Insurance Coverage
6. Reward Performance for Quality and Efficiency
5. Expand the Use of Interoperable Information Technology
57
Minnesota Smart-Buy Alliance
• Initiated in 2004 – alliance between state, private businesses, and labor groups
• Purchase health insurance for 70% of state residents ~3.5 million people
• Pool purchasing power to drive value in health care delivery system
• Set uniform performance standards, cost/quality reporting requirements & technology demands
• Four key strategies:
1. Reward or require “best in class” certification
2. Adopt and utilize uniform measures of quality and results
3. Empower consumers with easy access to information
4. Require use of information technologyTHE
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Washington State Puget Sound Health Alliance
• Founded in 2004 as independent non-profit organization
• Five-county partnership among employers, physicians, hospitals, consumers, health plans and others
• Multi-prong approach to improving care and “systemness”
– Developing evidence-based guidelines for physicians, hospitals and other health care professionals
– Designing tools for consumers and patients to support decision making & self management of chronic conditions
– Producing regional reports on quality, cost & value to be made publicly available by end of 2006
– Promoting data sharing across health plans & providers with the goal of a shared data repository
– Building regional infrastructure to support and sustain QI, including workforce development & training
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West Virginia Small Business PlanLeveraging Purchasing Power
• Enacted March 2004
• Partnership between WV Public Employees Insurance Agency (PEIA) & private market insurers
• Small business insurers pay providers at same rates negotiated by PEIA
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Several States Looking to More Comprehensive Health Reform Statewide
• Maine, Maine, Vermont, Rhode Island have quality initiatives built into coverage expansions
• Maine
– Created Maine Quality Forum to advocate for high quality health care and help each Maine citizen make informed health care choices.
• Massachusetts
– Cost and Quality Council formed
• Vermont
– Quality improvement initiatives
• Public-private collaboration
• Collection of health care data from all payers
• Provides rules to publicly report price & quality information THE
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Moving ForwardMoving Forward
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National Legislative Proposals to Facilitate State Health Insurance Innovations
• Baldwin-Price: Health Partnership through Creative Federalism– State proposals for coverage, quality and
efficiency and information technology. Statewide or multi-state
– Commission to review
• Voinovich-Bingaman: Health Partnership Act– State grants for innovation, priority to coverage
and access– Commission to establish performance measures
and goals and review proposals
• Multiple proposals to expand federal match for coverage to higher poverty levels and adults THE
COMMONWEALTH FUND
63What States Can Do Promote a High Performance
Health System: Strategies to Expand Coverage
• Develop blueprints toward more universal coverage
• Expand public programs and “connect” with private
• Provide financial assistance for affordability – premium assistance; “buy-in” provisions
• Assure benefit designs that cover primary, preventive and essential care
• Pool risk and purchasing power, partnerships with employers
• Pool purchasing power
• Efficient insurance arrangements
• Develop reinsurance programs to make coverage more affordable, pool risk and stabilize group rates
• Mandate that employers offer and/or individuals purchase coverage THE
COMMONWEALTH FUND
64What States Can Do to Promote a High Performance
Health System: Strategies to Improve Quality and Efficiency
• Promote
• Evidence-based medicine
• Effective chronic care management
• Transitional care post-hospital discharge
• Encourage data transparency and performance reporting
• Promote/practice value-based purchasing
• Promote the use of health information technology
• Encourage selection of medical home and improved access to primary care and preventive services
• Simplify and streamline public program eligibility and re-determination; Insurance
• Promote wellness and healthy livingTHE
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Laboratories for ChangeLaboratories for ChangeContinue to Lead the Way to Achieving a Continue to Lead the Way to Achieving a
High Performance Health System!High Performance Health System!
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Selected Commonwealth Fund Publications
• The Commonwealth Fund Commission on a High Performance Health System, Framework for a High Performance Health System for the United States, The Commonwealth Fund, August 2006
• The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 2006
• C. Schoen and S.K.H. How, National Scorecard on U.S. Health System Performance: Complete Chartpack and Chartpack Technical Appendix, The Commonwealth Fund, September 2006.
• S. Silow-Carroll and F. Pervez, States in Action: A Quarterly Look at Innovations in Health Policy, The Commonwealth Fund, Summer 2006, Vol. 5.
• Forthcoming: State Scorecard on Health System Performance
All publications are available at http://www.cmwf.org
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Acknowledgements
Stephen C. Schoenbaum
Executive Vice President and Executive Director, Commission of a High Performance Health System
Karen Davis
President
Ilana Weinbaum
Program Associate
Sabrina How
Research Associate
Alyssa Holmgren
Research Associate
THE COMMONWEALTH
FUND
Anne Gauthier
Senior Policy Director, Commission of a High Performance Health System