glenn steele: achieving a high performance health system

THE COMMONWEALTH

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Achieving a High Performance Health System

Glenn D. Steele Jr., MDGeisinger Health System

Commission on a High Performance Health System

Nuffield Trust Annual Health Policy MeetingMarch 24, 2009

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THE COMMONWEALTH

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Achieving a High Performance Health System

• Commonwealth Fund Commission on a High Performance Health System

• U.S. Health System Performance• What can Health Leaders Do to Reach High

Performance?

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THE COMMONWEALTH

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Commonwealth Fund Commission on a High Performance Health System:

2008 US Scorecard: Why Not the Best?

Chairman: James J. Mongan, MDPresident and CEO Partners HealthCare System, Inc.

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THE COMMONWEALTH

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Goals for a High Performance Health 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

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2008 Commission Scorecard Methodology

• 37 indicators on five dimensions of health system performance: healthy lives, quality, access, efficiency, and equity

• Scores are simple ratios of U.S. average performance to benchmarks– Benchmarks are levels achieved by other

countries or top U.S. states, regions, health plans, or providers

– Benchmarks typically based on performance of top 10 percent of hospitals, insurance plans, states

• To calculate average dimension scores, we average ratio scores for all indicators within dimension

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5

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THE COMMONWEALTH

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National Scorecard onHealth System Performance

75

72

67

52

70

67

72

71

58

53

71

65

0 100

Healthy Lives

Quality

Access

Efficiency

Equity

OVERALL SCORE

2006 Revised

2008

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

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THE COMMONWEALTH

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Mirror Mirror: US Falls 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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International Comparison of Spending on Health, 1980–2006

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

United StatesGermanyCanadaNetherlandsFranceAustraliaUnited Kingdom

0

2

4

6

8

10

12

14

16

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

United StatesGermanyNetherlandsCanadaFranceAustraliaUnited Kingdom

* PPP=Purchasing Power Parity.Source: OECD Health Data 2008, Version 06/2008.

Average spending on healthper capita ($US PPP*)

Total expenditures on health as percent of GDP

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THE COMMONWEALTH

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7681

88 84 89 8999 97

8897

109 106116 115 113

130 134128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

Fran

ceJa

pan

Austra

liaSpa

in

Italy

Canad

aNor

wayNeth

erlan

dsSwed

enGre

ece

Austri

aGer

many

Finlan

dNew

Zeala

ndDen

mark

United

King

dom

Irelan

dPor

tuga

lUnit

ed S

tates

1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.Data: E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71

Mortality Amenable to Health CareHEALTHY LIVES


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THE COMMONWEALTH

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32

46

53

47

49

50

58

39

0 20 40 60 80 100

Uninsured all year

Uninsured part year

Insured all year

<200% of poverty

200%–399% of poverty

400%+ of poverty

2005

2002

QUALITY: EFFECTIVE CARE

Receipt of Recommended Screening and Preventive Care for Adults

Percent of adults (ages 18+) who received all recommended screening andpreventive care within a specific time frame given their age and sex*

* Recommended care includes seven key screening and preventive services: blood pressure, cholesterol, Pap, mammogram,fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot. See Appendix B for complete description.Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.

U.S. Variation 2005

U.S. Average


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THE COMMONWEALTH

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Hospital Standardized Mortality Ratios

8593 94 97 100 103 106 106

112118

7076 81 84 84 87 90 91 94

105

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10

2000-2002 2003-2005

Ratio of actual to expected deaths in each decile (x 100)

Decile of hospitals ranked by actual to expected deaths ratiosSee Technical Appendix for methodology.Data: B. Jarman analysis of Medicare discharges from 2000 to 2002 and from 2003 to 2005 for conditions leading to 80 percent ofall hospital deaths.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, July 2008

Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors. Medicare national average for 2000 = 100

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THE COMMONWEALTH

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2017

12 14 1613

20

28

16

2522 24

3226

0

25

50

AUS CAN GER NETH NZ UK US

All Adults 2+ Chronic Conditions

Any Medical, Medication, or Lab Error in Past Two Years

Percent any error

Note: Errors include medical mistake, wrong dose/medication, or lab test error.Source: 2007 Commonwealth Fund International Health Policy Survey

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THE COMMONWEALTH

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Diabetes**

98

374

144 110

390

WhiteBlack

Hispanic

$45,000+

< $25,000

Heart failure Pediatric asthma

178

667

444

173

554

WhiteBlack

Hispanic

$45,000+

< $25,000

240

520

392

904

0

500

1000

WhiteBlack

Hispanic

$45,000+

< $25,000

Adjusted rate per 100,000 population

Ambulatory Care–Sensitive Hospital Admissions, by Race/Ethnicity and Patient Income Area, 2004/2005*

* 2004 data for diabetes and pediatric asthma; 2005 data for heart failure. ** Combines 4 diabetes admission measures: uncontrolled, short-term complications, long-term complications, and lower extremity amputations. Patient Income Area=median income of patient zip code. NA=data not available.Data: Race/ethnicity—Healthcare Cost and Utilization Project, State Inpatient Databases and National Hospital Discharge Survey (AHRQ 2007); Income area—HCUP, Nationwide Inpatient Sample (AHRQ 2007, retrieved from HCUPnet at http://hcupnet.ahrq.gov).

NA

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EQUITY: COORDINATED AND EFFICIENT CARE


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THE COMMONWEALTH

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1816

2021

15 1619 20

14

18

0

10

20

30

2003 2005 10th 25th 75th 90th 10th 25th 75th 90th

Medicare Hospital 30-Day Readmission Rates

Hospital Percentiles, 2005 State Percentiles, 2005


Percent of Medicare beneficiaries admitted for one of 31 select conditions who are readmitted within 30 days following discharge*

* See Appendix B for list of conditions used in the analysis.Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data.

EFFICIENCY

U.S. Mean

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THE COMMONWEALTH

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26 2849 48

13 16

914

19 24

411

0

25

50

75

100

2003 2007 2003 2007 2003 2007

Underinsured*

Uninsured during year

Uninsured and Under-insured Adults, 2007 Compared with 2003

ACCESS


Total 200% of poverty or moreUnder 200% of poverty

* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income,or 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Data: 2003 and 2007 Commonwealth Fund Biennial Health Insurance Survey.

Percent of adults (ages 19–64) who are uninsured or underinsured

4235

1727

68 72

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THE COMMONWEALTH

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Access Problems Because of Costs, 2007

37

58

12

2125 26

0

25

50

US 2007 NETH UK CAN GER NZ AUS

International Comparison, 2007

* Did not get medical care because of cost of doctor’s visit, skipped medical test, treatment, or follow-up because of cost, or did not fill Rx or skipped doses because of cost.AUS=Australia; CAN=Canada; GER=Germany; NET=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2004 and 2007 Commonwealth Fund International Health Policy Surveys.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

Percent of adults who had any of three access problems* in past year because of costs

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THE COMMONWEALTH

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Length of Time with Regular Doctor, Sicker Adults, 2005

Percent: AUS CAN GER NZ UK US

Has regular doctor 92 92 97 94 96 84

Less than 2 years 16 12 6 19 14 17

5 years or more 56 60 76 57 66 42

No regular doctor 8 8 3 6 4 16

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

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THE COMMONWEALTH

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Primary Care Doctors in U.S. Less Likely to Have Arrangement for Patients’ After-Hours Care to See

Nurse/Doctor

9590 87

8176

4740

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

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95

7972

58

43 4130

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 U.S. Less Likely to Receive Incentives for Quality

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THE COMMONWEALTH

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Physicians’ Use of Electronic Health Records

17

28

9892 89

79

42

23

0

25

50

75

100

NETH NZ UK AUS GER CANInternational Comparison

AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.Data: 2001 and 2006 Commonwealth Fund International Health Policy Survey of Physicians.

EFFICIENCY

Percent of primary care physicians using electronic medical records


2001 2006

United States

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THE COMMONWEALTH

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Percentage of National Health Expenditures Spent on Insurance Administration, 2005

a 2004 b 2001* Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance.Data: OECD Health Data 2007, Version 10/2007.

Net costs of health insurance administration as percent of national health expenditures

EFFICIENCY

1.92.3

2.83.3

3.9 4.2 4.34.8

5.6

6.97.5

0

2

4

6

8

10

Finland

Japan

Australi

a

United Kingdom

Austria

Canada

Netherla

nds

Switzerla

nd

German

y

France

United Stat

es*


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THE COMMONWEALTH

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Lessons from International Comparisons

• Gaps between average performance and benchmarks make compelling case for change

• What receives attention gets improved• Country patterns reflect underlying strategic policy choices

– National leadership on health policy matters– Universal coverage matters– Having an integrated healthcare “system” matters

• Better primary care and care coordination hold potential for improved outcomes at lower costs

• Align incentives to promote more effective and efficient use of staff, IT, and clinical resources

• Health information technology has significant potential but needs to be coupled with physician leadership and buy-in, care redesign, incentives

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THE COMMONWEALTH

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Policy Drivers for High Performance

• Extending affordable health insurance to all

• Organizing care around the patient

• Aligning financial incentives to enhance value and achieve savings

• Meeting and raising benchmarks for high quality, efficient care

• Ensuring accountable national leadership and public/private collaboration

Source: Commission on a High Performance Health System, A High Performance Health System for the United States: An Ambitious Agenda for the Next President, The Commonwealth Fund, November 2007

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THE COMMONWEALTH

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Total National Health Expenditures (NHE), 2009–2020 Current Projection and Alternative Scenarios

5.2

4.6

2.6

4.2

$1

$2

$3

$4

$5

$6

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Current projection (6.7% annual growth)

Path proposals (5.5% annual growth)

Constant (2009) proportion of GDP (4.7% annual growth)

NHE in trillions

Cumulative reduction in NHE through 2020: $3 trillion

Note: GDP = Gross Domestic Product.Data: Estimates by The Lewin Group for The Commonwealth Fund.Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009.

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THE COMMONWEALTH

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Trend in the Number of Uninsured, 2009–2020 Under Current Law and Path Proposal

48.9 50.3 51.8 53.3 54.7 56.0 57.2 58.3 59.2 60.2 61.1

48.0

6.3 4.0 4.1 4.1 4.1 4.1 4.2 4.2 4.2 4.2

48.0

19.7

0

20

40

60

80

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Current law

Path proposal

Millions

Note: Assumes insurance exchange opens in 2010 and take up by uninsured occurs over two years. Remaining uninsured are mainly non-tax-filers.Data: Estimates by The Lewin Group for The Commonwealth Fund.Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009.

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THE COMMONWEALTH

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Major Sources of Savings Compared with Projected Spending, Net Cumulative Reduction of National Health Expenditures, 2010–2020

Affordable Coverage for All: Ensuring Access and Providinga Foundation for System Reform• Net costs of insurance expansion –$94 billion• Reduced administrative costs –$337 billion

Payment Reform: Aligning Incentives to Enhance Value• Enhancing payment for primary care –$71 billion• Encouraging adoption of the medical home model –$175 billion• Bundled payment for acute care episodes –$301 billion• Correcting price signals –$464 billion

Improving Quality and Health Outcomes: Investing in Infrastructureand Public Health Policies to Aim Higher • Accelerating the spread and use of HIT –$261 billion• Center for Comparative Effectiveness –$634 billion• Reducing tobacco use –$255 billion• Reducing obesity –$406 billion

Total Net Impact on National Health Expenditures, 2010–2020 –$2,998 billion

Data: Estimates by The Lewin Group for The Commonwealth Fund.Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009.

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THE COMMONWEALTH

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Estimated Premiums for New Public Plan Compared with Average Individual/Small Employer Private Market, 2010

$2,904

$8,988

$4,164

$10,800

$0

$5,000

$10,000

$15,000

Single Family

Public plan Private plans outside exchange, small firms

Average annual premium for equivalent benefits at community rate*

Public plan premiums 20%–30% lower than traditional fee-for-service insurance

* Benefits used for modeling include full scope of acute care medical benefits; $250 individual/$500 family deductible; 10% coinsurance for physician service; 25% coinsurance and no deductible for prescription drugs; reduced for high-value medications; full coverage checkups/preventive care. $5,000 individual/$7,000 family out-of-pocket limit. Note: Premiums include administrative load.Data: Estimates by The Lewin Group for The Commonwealth Fund.Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009.

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THE COMMONWEALTH

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Path Net Cumulative Impact on National Health Expenditures (NHE) 2010–2020 Compared with

Baseline, by Major Payer Groups

Total NHENet

federalgovernment

Net state/local

government

Private employers Households

2010–2015 –$677 $448 –$344 $111 –$891

2010–2020 –$2,998 $593 –$1,034 –$231 –$2,325

Dollars in billions

Note: A negative number indicates spending decreases compared with projected expenditures (i.e., savings);a positive indicates spending increases.Data: Estimates by The Lewin Group for The Commonwealth Fund.Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009.

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THE COMMONWEALTH

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Savings Can Offset Federal Costs of Insurance: Federal Spending Under Two Scenarios

$99

$169

$250

$70 $62

$4$0

$50

$100

$150

$200

$250

$300

$350

2010 2015 2020

Net federal spending with insurance alone

Federal spending with insurance plus payment and system

Dollars in billions

Data: Estimates by The Lewin Group for The Commonwealth Fund.Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009.

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THE COMMONWEALTH

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Agenda for Change

• The U.S. has an historic opportunity to adopt reforms that will achieve a high performance health system

• The key ingredient is instituting a reform proposal that will ensure quality, affordable health insurance for all– The U.S. has Building Blocks form the foundation for expansion

of health insurance to all• Coverage for all must be pursued simultaneously with

comprehensive reforms in cost, quality and access– Payment reform to encourage integrated health care

organizations and other providers to be accountable for results and resources

– Rewarding primary care and patient-centered medical homes– Instituting a global fee covering hospital, physician, and other

services including 30-day follow-up for acute episodes of care– Incentives for adoption of information technology– Information on comparative effectiveness and evidence-based

medicine

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THE COMMONWEALTH

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What can Health Leaders Do to Reach High Performance?

• Meet and raise benchmark levels of performance– Invest in chronic care improvement, transitional care– Improve patient-centered care; survey and respond to

patient concerns• Support transparency; public reporting of clinical quality,

patient-centered care, and efficiency• Share and help spread best practices • Accelerate adoption of IT and functionality; ensure patient

access to an integrated personal health record • Participate in innovative reform initiatives that reward high

quality and efficient care• Train a future generation of leaders to deliver a high

performance health system that achieves better access, improved quality, and greater efficiency

glenn steele: achieving a high performance health system

Health & Medicine