Transcript THE COMMONWEALTH FUND Transforming The U.S. Health System: What Needs To Be Done & Your Role Stephen C.

THE
COMMONWEALTH
FUND
Transforming The U.S. Health System:
What Needs To Be Done & Your Role
Stephen C. Schoenbaum, MD, MPH
Executive Vice President for Programs
www.cmwf.org
Mountainside Hospital
February 8, 2007
What We’ll Cover
• Introduction to The Commonwealth
Fund and The Commission on a High
Performance Health System
• Goals for a high performance health
system
• Where we stand now
• Keys to transforming the health system
• What you can do
THE
COMMONWEALTH
FUND
The Commonwealth Fund
Established in 1918, The
Commonwealth Fund
(www.cmwf.org) is a private
national foundation that
aims to promote a high
performing health care
system by supporting
independent research on
health care issues and
making grants to improve
health care practice and
policy.
THE
COMMONWEALTH
FUND
The Commonwealth Fund Commission on a High
Performance Health System
Chairman: James J. Mongan, M.D.
President and CEO Partners HealthCare
System, Inc.
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 and ethnicity, health, or
age
THE
COMMONWEALTH
FUND
Goals for a High Performance
Health System
HIGH QUALITY, SAFE,
COMPASSIONATE,
ACCESS AND EQUITY
FOR ALL
COORDINATED CARE
LONG,
HEALTHY,
AND
PRODUCTIVE
LIVES
EFFICIENCY
CAPACITY FOR SYSTEM
AND WORKFORCE
INNOVATION AND
IMPROVEMENT
THE
COMMONWEALTH
FUND
Scores: Dimensions of a High
Performance Health System
0
Long, Healthy, &
Productive Lives
69
Quality
71
Access
Efficiency
67
51
Equity
OVERALL SCORE
71
66
THE
COMMONWEALTH
FUND
SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
LONG, HEALTHY & PRODUCTIVE LIVES
Mortality Amenable to Health Care
Mortality from causes considered amenable to health care is deaths before age 75
that are potentially preventable with timely and appropriate medical care.
Deaths per 100,000 population*
International Variation, 1998
150
State Variation, 2002
129 130 132
106 107 109 109
134
119
115 115
110
103
97 97 99
100
75
81 84
88 88 88
92
90
84
50
Fr
an
ce
Ja
pa
n
Sp
a
Sw in
ed
en
I
Au taly
st
ra
Ca lia
na
d
No a
Ne
r
th w a
er y
la
nd
s
G
re
G e ce
er
m
an
y
A
Ne
us
w
Ze tria
al
a
De nd
Un n
ite ma
rk
d
St
at
Fi es
nl
an
Un
d
I
ite
re
l
d
Ki and
ng
do
Po m
rtu
ga
l
0
U
.A
.S
e
ag
r
ve
h
t
10
t
25
h
M
n
ia
d
e
h
t
75
h
t
90
Percentiles
THE
COMMONWEALTH
FUND
U.S. Adults Receive Half of Recommended Care;
Quality Varies Significantly by Medical Condition
Percent of recommended care received
76
80
60
65
55
54
45
40
39
23
20
0
Overall
Breast
Hypertension
Asthma
Diabetes
Pneumonia
Hip Fracture
Cancer
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.
THE
COMMONWEALTH
FUND
Patients Reporting Any Error by Number
of Doctors Seen in Past Two Years
Percent
75
1 doctor
48
50
25
4 or more doctors
40
37
12
35
31
15
14
14
28
22
12
0
AUS
CAN
GER
NZ
UK
US
THE
COMMONWEALTH
FUND
2005 Commonwealth Fund International Health Policy Survey
ACCESS: UNIVERSAL PARTICIPATION
Number of States with High Proportion of Uninsured Adults
Ages 18–64 Is Growing
1999–2000
2004–2005
NH
NH ME
VT
WA
MT
NH
WA
ND
VT
OR
ID
NY
WI
SD
MI
WY
PA
IA
NE
UT
OH
IN
NV
CA
IL
CO
MA
KS
MO
WV
VA
KY
NJ
RI
CT
MN
OR
ID
MI
PA
IA
NE
CA
IL
CO
KS
MO
AZ
NM
MS
TX
AL
DE
MD
DC
NC
AZ
GA
NM
OK
SC
AR
MS
LA
TX
AL
GA
LA
FL
AK
VA
NJ
RI
CT
TN
SC
AR
WV
KY
TN
OK
OH
IN
NV
UT
MA
NY
WI
SD
WY
DE
MD
DC
NC
ME
ND
MT
MN
FL
AK
HI
23% or more
19%–22.9%
HI
14%–18.9%
Less than 14%
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.
Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
THE
COMMONWEALTH
FUND
EFFICIENCY
Quality and Costs of Care for Medicare Patients
Hospitalized for Heart Attacks, Colon Cancer and Hip
Fractures, by Hospital Referral Regions, 2000-2002
Quality of Care*
(1 Year Survival Index, Median = 70%)
1.20
Median Relative Resource Use = $25,995
1.10
1.00
0.90
0.80
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
Relative Resource Use**
* 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: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
THE
COMMONWEALTH
FUND
Variation in Annual Total Cost and Quality for
Chronic Disease Patients
Quality of Care* and Medicare Spending for Beneficiaries with
Three Chronic Conditions, by Hospital Referral Region
1.60
Average Quality of Care Score
1.40
Best Practice Curve
Greenville, NC
Ft. Lauderdale, FL
East Long Island, NY
Orange County, CA
Hackensack, NJ
1.20
Manhattan, NY
New Brunswick, NJ
Camden, NJ
1.00
Newark, NJ
0.80
Saginaw, MI
0.60
0.40
Median Amount Spent per Patient
per HRR = $28,694
0.20
0.00
$-
$10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000
Average Annual Reimbursement per Beneficiary (Wage-Index Adjusted)
THE
COMMONWEALTH
FUND
EFFICIENCY
International Comparison of Spending on Health, 1980–
2004
Average spending on health
Total expenditures on health
per capita ($US PPP)
7000
6000
United States
Germany
Canada
France
Australia
United Kingdom
as percent of GDP
16
14
12
5000
10
4000
8
3000
6
2000
4
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
0
2
0
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
1000
United States
Germany
Canada
France
Australia
United Kingdom
Data: OECD Health Data 2005 and 2006.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
THE
COMMONWEALTH
FUND
13
EFFICIENCY
Percentage of National Health Expenditures Spent
on Health Administration and Insurance, 2003
Net costs of health administration and health insurance as percent of national health expenditures
8
7.3
5.6
6
4.8
4.1
4.0
4
4.2
3.3
St
at
es
m
an
y
U
ni
te
d
G
er
er
la
n
Sw
itz
ra
lia
us
t
ria
A
et
h
N
in
g
K
d
*
U
ni
te
us
t
do
m
da
an
a
d
c
b
C
pa
n
Ja
d
Fi
nl
an
Fr
an
ce
a
A
0
nd
s
1.9
2
2.6
2.1
er
la
2.1
THE
COMMONWEALTH
FUND
Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
The Discourse Has Changed
FROM:
• “Americans have the best health care system
in the world”
– President Bush, State of the Union Speech, 2004
TO:
• We need to do better
– We spend more on health care than any other
country
– We need more value for what we are spending
THE
COMMONWEALTH
FUND
We Know The Problems
Now We Need Solutions
THE
COMMONWEALTH
FUND
Keys to Transforming
the U.S. Health Care System
1.
2.
3.
4.
5.
6.
7.
Guarantee affordable health insurance coverage
Implement major quality and safety improvements
Work toward a more organized delivery system that emphasizes
primary and preventive care and is patient-centered
Increase transparency and reporting on quality and costs
Expand the use of interoperable information technology
Reward performance on quality and efficiency
Encourage public-private collaboration to achieve simplification,
more effective change
THE
COMMONWEALTH
FUND
Guarantee Affordable Health Insurance
Coverage
1. Guarantee Affordable Health
Insurance Coverage
THE
COMMONWEALTH
FUND
What Are the Most Important Health Care Issues
for Presidential and Congressional Action?
Percent listing issue as
first or second priority:
Total
Less than
$50,000
$50,000–
$74,999
$75,000
or more
Ensure that all Americans have adequate,
reliable health insurance
52
56
52
50
Control the rising cost of medical care
37
35
42
39
Lower the cost of prescription drugs
31
31
27
33
Ensure that Medicare remains financially
sound in the longterm
29
29
32
30
Improve the quality of nursing homes and
long-term care
14
16
15
13
Reform the medical malpractice system
14
10
12
18
Reduce the complexity of insurance
12
12
10
10
Source: C. Schoen, S.K. How, I. Weinbaum, J.E. Craig, Jr., and K. Davis, “Public Views on Shaping
the Future of the U.S. Health System,” The Commonwealth Fund, August 2006.
THE
COMMONWEALTH
FUND
Why Do We Need Universal
Coverage?
• Waste
– cost-shifting
– ineffective care (poorer adherence)
– duplication
– back-end vs. front-end care
• Societal benefit
It’s Not Just Altruism
THE
COMMONWEALTH
FUND
The Action Now Lies In States
• Single payer isn’t likely
• Common elements
– Expand public programs (cover more poor
people)
– Require individual participation
– Require employer participation
THE
COMMONWEALTH
FUND
Massachusetts Health Plan
• MassHealth expansion for children
up to 300% Federal Poverty Level;
adults up to 100% FPL
• 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
California Governor’s Proposal
• Individual mandate
• Premium subsidies for adults below
250% federal poverty level
• Employer offer health insurance or
pay 4% of wages into pool
• Provider fee assessment (2% of
physician revenues to 4% of
hospital revenues)
• Insurance market regulation
– Guaranteed issue
– Community rating with age bands
– 85 percent minimum medical loss ratio
THE
COMMONWEALTH
FUND
• Effective May, 2006: New law in New
Jersey allowing persons up to age 30 to
be covered under their parents’ insurance
THE
COMMONWEALTH
FUND
Implement Major Quality and Safety
Improvements
1. Guarantee Affordable Health
Insurance Coverage
2. Implement Major
Quality and Safety
Improvements
THE
COMMONWEALTH
FUND
CCU / MICU Aggregate
Central Line Infection Data
9
8
7
NNIS
CCU/M ICU
PRHI
Richard
Shannon, MD
Initiate PRHI /TPS
Proce ss
6
5
4
3
2
1
0
2003
Allegheny General Hospital
2004
Highmark “Quality Blue” Year 4
MRSA
UPMC FY 2006 (Oct. - March) Hospital Acquired MRSA Case Trending
FY 2006 Hosp. Acq. MRSA Cases
25
20
15
10
5
0
Baseline
OCT. 2005
NOV. 2005
DEC. 2005
JAN. 2006
FEB. 2006
MAR. 2006
Presbyterian CTICU
10
1
2
1
2
1
1
Shadyside MICU
7
1
1
0
0
0
3
McKeesport Med-Surg
1
0
0
0
0
0
1
St. Margaret Med-Surg Teach
6
2
2
1
1
3
0
Totals
24
4
5
2
3
4
5
Institute for Healthcare Improvement
100K Lives Campaign: Success Story
THE
COMMONWEALTH
FUND
Patient-Centered Hospital Care:
Staff Managed Pain, Responded When Needed
Help, and Explained Medicines, 2005
Percent of patients reporting “always”
Average
Best Hospital
10th %ile Hospitals
100
93
100
90th %ile Hospitals
91
79
74
70
61
50
70
63
52
60
49
0
Staff managed pain well *
Staff responded when needed Staff explained medicines and
help **
side effects***
THE
COMMONWEALTH
FUND
Reid Hospital; Richmond, Indiana
2004
HQA
Ave.
AMI:ACEI
when
appropriate
CHF: LV
assessment
75
Reid
Hospital
Q4 2004
100
78
99
CAP:
Pneumococcal
Vaccine
46
100
THE
COMMONWEALTH
FUND