A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency
description
Transcript of A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency
THE COMMONWEALTH
FUND
A Need to Transform the U.S. Health A Need to Transform the U.S. Health Care System: Improving Access, Care System: Improving Access,
Quality, and EfficiencyQuality, and Efficiency
A ChartbookA Chartbook
Compiled byCompiled by Anne Gauthier, Senior Policy Director Anne Gauthier, Senior Policy Director
Michelle Serber, Program AssistantMichelle Serber, Program Assistant
2
THE COMMONWEALTH
FUND
ContentsContents
Acknowledgments
Overview
I. Need for Better Accessand Coverage
II. Need for Quality Enhancements
III. Need for GreaterEfficiency
Conclusion. The Time IsRipe for Improvement
References
• 3
• 4
• 6
• 28
• 57
• 80
• 86
Commonwealth Fund pub. no. 867.
3
THE COMMONWEALTH
FUND
Acknowledgments Acknowledgments
This chartbook is a compilation of data that represents the work of many individuals at The Commonwealth Fund. We wish to thank those who kindly provided data, information, research, and assistance:
Anne-Marie J. Audet, M.D., Vice President, Quality ImprovementSara R. Collins, Ph.D., Senior Program OfficerJohn E. Craig, Jr., Executive Vice President and Chief Operating OfficerKaren Davis, Ph.D., PresidentMichelle M. Doty, Ph.D., Senior AnalystPaul D. Frame, Production EditorStuart Guterman, Senior Program DirectorAlice Ho, former Research AssociateChristopher Hollander, Associate Communications DirectorAlyssa L. Holmgren, Research AssociatePhuong Trang Huynh, Ph.D., Associate DirectorCathy Schoen, Senior Vice President, Research and EvaluationStephen C. Schoenbaum, M.D., Executive Vice President for ProgramsIlana Weinbaum, Program Associate
4
THE COMMONWEALTH
FUND
OverviewOverviewThe need for fundamental transformation of the U.S. health care system has become increasingly apparent. Research reveals a fragmented system fraught with waste and inefficiency. Among industrialized nations, the United States spends well over twice the per capita average (Reinhardt et al. 2004). High spending, however, has not translated into better health: Americans do not live as long as citizens of several other industrialized countries, and disparities are pervasive, with widespread differences in access to care based on insurance status, income, race, and ethnicity.
Particularly problematic is the large number of individuals lacking ready access to health services. Over a third of the population is uninsured, unstably insured, or underinsured (Schoen et al. 2005). With health care costs on the rise, affordability is a key concern for many working families. Gaps in insurance coverage and high out-of-pocket spending hinder patients' access to care and lead to skipped medical tests, treatments, and follow-up appointments. In turn, these access problems produce preventable pain, suffering, and death—as well as more expensive care.
5
THE COMMONWEALTH
FUND
There are also significant issues with the safety and quality of care. As many as 98,000 deaths result annually from medical errors (Kohn et al. 1999), and U.S. adults receive only 55 percent of recommended care (McGlynn et al. 2003). Inefficiencies, such as duplication and use of unnecessary services, are costly and compromise the quality of care. High administrative costs in health insurance and health care delivery are also problems.
The following sections further illustrate the need to improve coverage, quality, and efficiency. The charts presented paint a stark picture of a health system in need of reform. Clearly, moving the nation toward a high performance health system will require collaboration. That is why The Commonwealth Fund has formed the Commission on a High Performance Health System: to identify public and private strategies, policies, and practices that would lead to improvements in the delivery and financing of health care for all Americans.
6
THE COMMONWEALTH
FUND
I. Need for Better Access and CoverageI. Need for Better Access and CoverageNumber of uninsured individuals are on the rise.
In 2004, 45.8 million individuals in the United States were uninsured (U.S. Census Bureau),* and projections indicate that the number of uninsured individuals may exceed 50 million by the end of the decade (Chart I-1). The following are findings pertaining to the uninsured:
– According to health care opinion leaders, the uninsured should be a top priority for Congress (Chart I-2).
– Between 2000 and 2004, the number of uninsured individuals increased by 5.8 million. Adults ages 18 to 64 comprised all of the increase (Chart I-3).
– Between 1987 and 2003, the working middle class saw the greatest increase in uninsured individuals (Chart I-4).
– Among the uninsured, low-income families and adults are disproportionately represented (Chart I-5).
– Uninsured rates vary widely by state (Chart I-6).
* The CPS asks about insurance coverage in the previous year. An individual is considered "uninsured" if he or she was not covered by any type of health insurance at any time in that year.
7
THE COMMONWEALTH
FUND
Job-based premium increases, gaps in coverage, and underinsurance contribute to access problems.
In 2003, 45 million U.S. adults were uninsured at some point during the year (Schoen et al. 2005).** Contributing to problems with access are job-based premium increases overtaking wage increases. The year 2004 saw increases in premiums greatly outpace workers' earnings from the previous year (Chart I-7). The Commonwealth Fund Biennial Health Insurance Survey (2003) highlighted the growing problem of underinsurance:***
– 26 percent of U.S. adults 19 to 64 were either uninsured all year or part of the year (Chart I-8).
– Another 9 percent of adults, or 16 million people, were underinsured (Chart I-8).
– Added together, 61 million adults—one-third of adults under 65—were either uninsured or underinsured during the year (Chart I-8).
** Schoen et al. used the term uninsured to refer to individuals who had been uninsured for some time during the past year.*** An underinsured person is defined as one who has insurance all year but has inadequate protection, as indicated by one of three conditions: 1) annual out-of-pocket medical expenses amount to 10 percent or more of income; 2) among low-income adults (with income below 200 percent of the federal poverty level), out-of-pocket expenses amount to 5 percent or more of income; or 3) health plan deductibles equal or exceed 5 percent of income.
8
THE COMMONWEALTH
FUND
Gaps in insurance coverage make it difficult for people to afford filling prescriptions; seeing a specialist when warranted; undergoing a medical test, treatment, or follow-up; or seeking advice for a medical problem. Of adults who were uninsured at the time of the survey, 61 percent reported encountering at least one of these access problems. Of those who were currently insured but had been uninsured at some point during the past year, a majority reported access problems. For those who had been insured all year, the percentage was much lower but still large (Chart I-9). The Institute of Medicine estimates that in 1999, being uninsured was the sixth-leading cause of death (Chart I-10).
Underinsured adults are also at high risk of going without needed care because of cost, as well as at high risk of experiencing financial stress. Rates on both access and financial indicators for the underinsured approach or equal those reported by the uninsured (Chart I-11). Even for adults covered all year by private insurance, barriers to access exist in several forms, including high out-of-pocket costs (Chart I-12).
9
THE COMMONWEALTH
FUND
Disparities persist by income and race.
For low-income adults (with income below 200 percent of the poverty level), unstable health coverage is a prevalent concern. Analysis of health insurance coverage and employment patterns over the four years 1996-99 indicates that at some point during this period, 68 percent of low-income adults were uninsured, compared with 26 percent of adults with higher incomes (Chart I-13). In addition to income, access also varies by race and ethnicity. In 2000, 50 percent of Hispanic adults were uninsured for all or part of the year, compared with 35 percent of African Americans and 22 percent of whites (Chart I-14).
Inadequate access leads to reduced productivity and output.
Individuals with no insurance, only sporadic coverage, or insurance that exposes them to catastrophic out-of-pocket costs are more likely to go without care. Receipt of primary and preventive care is associated with job compensation, and workers in the lowest-compensated positions are less likely to have a regular physician and to receive preventive care screens (Chart I-15). The majority of employers believe that health insurance positively affects employee health and morale. In addition, more than one-third of employers link health benefits to enhanced employee productivity (Chart I-16).
10
THE COMMONWEALTH
FUND
The effects of inadequate access go beyond individual health consequences, as gaps in coverage affect quality of care, health outcomes, and economic productivity. The Institute of Medicine estimated that preventable morbidity and mortality associated with being uninsured translates into a loss of $65 billion to $130 billion annually (Institute of Medicine 2003). Providing all workers with health insurance coverage would facilitate early treatment of acute illnesses and the ongoing management of chronic conditions, increase use of preventive care, and improve worker health and productivity (Davis et al. 2005).
The health of workers has economic implications.
More generally, substantial costs are incurred when workers are too sick to work or function effectively. According to the 2003 Biennial Health Insurance Survey, the majority of Americans experience reduced productivity, sick days, or health problems (Chart I-17). Affordable and comprehensive health insurance coverage and paid sick leave can improve the health of workers and their family members, which in turn could yield economic payoffs for working families and the economy as a whole (Davis et al. 2005). Since employers,and society as a whole, benefit from workers having insurance, it isimportant to strengthen employee coverage (Collins et al. 2005).
11
THE COMMONWEALTH
FUND
Chart I-1. 46 Million Uninsured in 2004; Projected Chart I-1. 46 Million Uninsured in 2004; Projected to Increase Substantiallyto Increase Substantially
* 1999–2004 estimates reflect the results of follow-up verificationquestions and implementation of Census 2000-based population controls.Note: Projected estimates for 2005–2013 are for nonelderly uninsured based on T. Gilmer andR. Kronick, "It's the Premiums, Stupid: Projections of the Uninsured Through 2013," Health Affairs Web Exclusive, April 5, 2005. Source: U.S. Census Bureau, March CPS Surveys 1988 to 2005.
31 33 33 35 3539 40 40 41 42 43 44
40 40 4144
56
45
0
20
40
60
1987 1990 1993 1996 1999* 2002 2005 2008 2011
Millions uninsured
Projected
2013
46
12
THE COMMONWEALTH
FUND
Chart I-2. Uninsured Top Priority for CongressChart I-2. Uninsured Top Priority for CongressAccording to Health Care Opinion LeadersAccording to Health Care Opinion Leaders
6%
21%
24%
27%
30%
31%
35%
38%
48%
50%
69%
87%
Control Medicaid costs
Improve quality of nursing homes and LTC
Medicaid reforms to improve coverage
Administrative simplification and standardization
Malpractice reform
Address racial/ethnic disparities in care
Control rising cost of prescription drugs
Medicare payment reform to reward performance onquality and efficiency
Enact reforms to moderate rising costs of medicalcare
Medicare reforms to ensure long-run solvency
Improve quality of medical care, inc. increased use ofIT
Expand coverage to the uninsured
Source: The Commonwealth Fund Health Care Opinion Leaders Survey, November–December 2004.
"Which of the following health care issues should be the toppriorities for Congress to address in the next five years?"
13
THE COMMONWEALTH
FUND
Chart I-3. Number Uninsured Rose 5.8 Million Chart I-3. Number Uninsured Rose 5.8 Million from 2000 to 2004, with Adults Accountingfrom 2000 to 2004, with Adults Accounting
for All of the Increase for All of the Increase
8.6
8.3
30.9
37.5
0 10 20 30 40 50
2000
2004
Under age 18 Ages 18–64
Source: U.S. Census, March 2001 and March 2005 Current Population Surveys.
45.8 million
40million
14
THE COMMONWEALTH
FUND
Chart I-4. Uninsured Rates IncreasingChart I-4. Uninsured Rates IncreasingMost Sharply for Working Middle ClassMost Sharply for Working Middle Class
47%50%
48%
52%
48%
39%
35%
44%
33%
21%
15%18%
25%
8%6%9%
11%
2%5%
4%
5%
0%
20%
40%
60%
1987 1989 1991 1993 1995 1997 1999* 2001 2003
Lowestquintile
Second
Third
Fourth
Highestquintile
* In 1999, CPS added a follow-up verification question for health coverage.Source: Analysis of the March 1988–2004 Current Population Surveys byDanielle Ferry, Columbia University, for The Commonwealth Fund.
Percent of working adults uninsured, by household income quintile 1987-2003
15
THE COMMONWEALTH
FUND
Other children5%
Other parents7%
Low-income adults without
children34%
Low-income parents
17%
Low-income children
15%
Other adults without children
22%
Chart I-5. Two-Thirds of NonelderlyChart I-5. Two-Thirds of NonelderlyUninsured Are Low-Income, 2003Uninsured Are Low-Income, 2003
Total = 44.7 million
Note: Low-income is defined as below 200% of the federal poverty level($29,360 for a family of three in 2003). Source: Kaiser Commission on Medicaid and Uninsured and Urban Instituteanalysis of the March 2004 Current Population Survey.
16
THE COMMONWEALTH
FUND
15%–17.9%
Less than 12%
12%–14.9%
18% or more
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
DC
HI
CO
GAMS
OK
NJ
SD
Chart I-6. Percent of Nonelderly UninsuredChart I-6. Percent of Nonelderly UninsuredPopulation Varies Widely by State, 2001–2003Population Varies Widely by State, 2001–2003
Source: Health Insurance Coverage in America: 2003 Data Update Highlights,Kaiser Commission on Medicaid and Uninsured/Urban Institute, September 27, 2004.Uninsured rates are two year averages, 2001–2003.
17
THE COMMONWEALTH
FUND
Chart I-7. Job-Based Premium Increases Chart I-7. Job-Based Premium Increases Greater than Wage IncreasesGreater than Wage Increases
12%
5%
8%
11%
13%14%
11%
1%
9%
14%
18%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
1988 1990 1992 1994 1996 1998 2000 2002 2004
Premiums
Workers' earnings
Source: "Employer Health Benefits 2004 Annual Survey," Kaiser Family Foundation/Health Research and Educational Trust, September 2004.
Percent change from previous year
2%
18
THE COMMONWEALTH
FUND
Chart I-8. Significant Percentage of Underinsured Chart I-8. Significant Percentage of Underinsured Adults Indicates Access to Care Not Just Issue for Adults Indicates Access to Care Not Just Issue for
UninsuredUninsured
Insured all year, not underinsured
65%
Underinsured9%
Uninsured all year13%
Uninsured part year13%
Source: C. Schoen et al., "Insured But Not Protected: How Many Adults Are Underinsured?" Health Affairs, June 2005, based on The Commonwealth Fund 2003 Biennial Health Insurance Survey.
Uninsured is defined as uninsured for some time during the past year.
19
THE COMMONWEALTH
FUND
12 13
2940
51
918
57
3935
18
40
61
2737
0
25
50
75
Did not fill a
prescription
Did not see
specialist when
needed
Skipped medical
test, treatment, or
follow-up
Had medical
problem, did not
see doctor or
clinic
Any of the four
access problems
Insured all year Insured now, time uninsured in past year Uninsured now
Chart I-9. Gaps in Insurance CoverageChart I-9. Gaps in Insurance CoverageHinder Access to CareHinder Access to Care
Source: S. R. Collins, M. M. Doty, K. Davis et al., The Affordability Crisis inU.S. Health Care: Findings From The Commonwealth Fund Biennial HealthInsurance Survey, The Commonwealth Fund, March 2004.
Percent of adults ages 19–64 reporting the following problems because of cost:
20
THE COMMONWEALTH
FUND
Chart I-10. Being Uninsured Is aChart I-10. Being Uninsured Is aLeading Cause of DeathLeading Cause of Death Deaths of Adults Ages 25–64, 1999Deaths of Adults Ages 25–64, 1999
1. Cancer — 156,485
2. Heart disease — 115,827
3. Injuries — 46,045
4. Suicide — 19,549
5. Cerebrovascular disease — 18,369
6. Uninsured — 18,000
7. Diabetes — 16,156
8. Respiratory disease — 15,809
9. Chronic liver disease and cirrhosis — 15,714
10. HIV/AIDS — 14,017
Sources: U.S. Department of Health and Human Services, National Center for Health Statistics, Health, United States, 2002, Table 33, p. 132 — deaths for causes other than uninsured; Instituteof Medicine, Care Without Coverage, Appendix D, p. 162, deaths attributable to higher risks of uninsured adults 25–54.
21
THE COMMONWEALTH
FUND
Chart I-11. Underinsured and Uninsured Adults at Chart I-11. Underinsured and Uninsured Adults at High Risk of Access ProblemsHigh Risk of Access Problems
and Financial Stressand Financial Stress
25
117
35
59
44
28
4654
0
25
50
75
Went without care
because of costs
Contacted by collection
agency about medical bills
Changed way of life
significantly to pay
medical bills
Insured, not underinsured Underinsured Uninsured during year
Percent of adults ages 19–64
* Did not fill a prescription; did not see a specialist; skippedrecommended care; or did not see doctor when sick because of costs.Source: C. Schoen et al., "Insured But Not Protected: How ManyAdults Are Underinsured?" Health Affairs Web Exclusive, June 14, 2005.
*
22
THE COMMONWEALTH
FUND
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
Chart I-12. Adults with Low and Moderate Chart I-12. Adults with Low and Moderate Incomes Spend Greatest Share of IncomeIncomes Spend Greatest Share of Income
on Out-of-Pocket Costson Out-of-Pocket Costs
Percent of adults ages 19–64 insured all year with private insurancewho spent 5 percent or more of income on out-of-pocket costs
Note: Income groups based on 2002 household income.
Source: S. R. Collins, M. M. Doty, K. Davis et al., The Affordability Crisis inU.S. Health Care: Findings From The Commonwealth Fund Biennial HealthInsurance Survey, The Commonwealth Fund, March 2004.
23
THE COMMONWEALTH
FUND
Chart I-13. Low-Income Adults, Especially Hispanics, Chart I-13. Low-Income Adults, Especially Hispanics, Have High Uninsured Rates over Four Years; Have High Uninsured Rates over Four Years;
Disparities Persist Across Income LevelsDisparities Persist Across Income Levels
4131
2326
80
666368
2316
1012
64
464247
0
25
50
75
100
Total White African
American
Hispanic Total White African
American
Hispanic
Any time uninsured Uninsured more than one year
200% or more of poverty
Percent of population 19–64 uninsured, 1996–1999
Under 200% poverty
Source: M. M. Doty and A. L. Holmgren, Unequal Access: Insurance InstabilityAmong Low-Income Workers and Minorities, The Commonwealth Fund, April 2004.Data: 1996 panel of the Survey of Income and Program Participation.
24
THE COMMONWEALTH
FUND
Chart I-14. Percent of Population Uninsured Chart I-14. Percent of Population Uninsured All Year or Part-Year VariesAll Year or Part-Year Variesby Race and Ethnicity, 2000by Race and Ethnicity, 2000
9 7 917 15 11
213414
1320
16
14
111413
0
25
50
75
Total White African
American
Hispanic Total White African
American
Hispanic
Uninsured part year
Uninsured all year
23 20 23
37
2822
35
50
Adults ages 19–64
Percent of population uninsured all year or part-year, 2000
Source: M. M. Doty. Insurance, Access, and Quality of Care Among Hispanic Populations:2003 Chartpack, The Commonwealth Fund, October 2003. Data: MEPS 2000.
Children ages 0–18
25
THE COMMONWEALTH
FUND
Chart I-15. Preventive and Primary Care Varies by Chart I-15. Preventive and Primary Care Varies by Workers' Job Compensation LevelsWorkers' Job Compensation Levels
64
74
54
74
84
66
89 9185
0
10
20
30
40
50
60
70
80
90
100
Regular doctor (ages 19–64) Blood pressure check in
past year (ages 19–64)
Cholesterol check in past
five years (ages 19–64)
Note: Lowest compensated are all workers with wage rate <$10/hr; mid-compensated are workers with wage rate $10-$15/hour and those >$15/hour but no employer-sponsored insurance; higher compensated are workers with wage rate >$15/hour and employer-sponsored insurance.Source: The Commonwealth Fund Biennial Health Insurance Survey (2003).
Lowest compensated Mid-compensated
Higher compensated
26
THE COMMONWEALTH
FUND
Chart I-16. Majority of Employers Believe ThatChart I-16. Majority of Employers Believe ThatHealth Benefits Improve Employee Health and MoraleHealth Benefits Improve Employee Health and Morale
6760
39
0
20
40
60
80
Improves employee
health
Improves employee
morale
Increases employee
productivity
Source: S. R. Collins et al., Job-Based Health Insurance in the Balance: Employer Views of Coverage in the Workplace, The Commonwealth Fund, March 2004; Commonwealth Fund Supplement to the 2003 National Organization Study.
Employers who say health benefits contributea great deal or quite a bit
Percent of firms offering coverage
27
THE COMMONWEALTH
FUND
Chart I-17. Majority of Americans Experience Chart I-17. Majority of Americans Experience Health Problems, Sick Loss, or Reduced Health Problems, Sick Loss, or Reduced
Productivity (all adults ages 19–64)Productivity (all adults ages 19–64)
Working with 6 or more sick days or reduced-productivity days
27%
Working with no sick days or reduced-productivity days
18%
Not working for other non-health reasons
21%
Working with 1 to 5sick days or reduced-
productivity days
21%
Not working because of disability or other health reasons
12%
Note: Numbers may not sum to 100% because of rounding. Excludes self-employed adults and workers with undesignated wage rate. Sick-loss days are days of work missed because self or family member was sick. Reduced-productivity days are days unable to concentrate fully at work because not feeling well or worried about sick family member.
Source: K. Davis et al., Health and Productivity Among U.S. Workers, The Commonwealth Fund, August 2005; The Commonwealth Fund Biennial Health Insurance Survey (2003).
28
THE COMMONWEALTH
FUND
II. Need for Quality EnhancementsII. Need for Quality EnhancementsQuality and cost of health care vary widely across the United States.
There are significant variations in the quality and cost of health care, both within the United States and internationally (Davis et al. 2004; Fisher et al. 2003). U.S. adults often do not receive the level of care that is recommended for a particular condition. One study indicates that overall, individuals received only 55 percent of recommended care, a proportion that varies based on the condition, as detailed below (McGlynn et al. 2003).
– Individuals being treated for breast cancer went without nearly one-fourth of recommended care, while those undergoing treatment for hypertension went without more than one-third of recommended care (Chart II-1).
– The figures for individuals being treated for asthma reflect even lower quality, with individuals receiving approximately half of the recommended care (Chart II-1).
– For those undergoing treatment for diabetes, pneumonia, or ahip fracture, the percentages of recommended care attainedwere even lower (Chart II-1).
29
THE COMMONWEALTH
FUND
The provision of appropriate care varies across the United States(Chart II-2). In a study examining the quality of care provided to Medicare beneficiaries, the authors ranked the states on 22 quality indicators. Substantial discrepancies exist among states ranked in the first quartile and those ranked in the fourth quartile, with northern states and less-populous states performing better (Jencks, Huff, and Cuerdon 2003).
Preventive care is often overlooked.
The 2004 Commonwealth Fund International Health Policy Survey indicates that 49 percent of respondents in the United States do not receive reminders for preventive care (Chart II-3). The proportions of young children and their families who receive preventive and developmental services are relatively low: only 30 to 40 percent of parents of young children reported receiving services such as anticipatory guidance, parental education, psychosocial assessment, or screening for tobacco and substance use (Chart II-4).
30
THE COMMONWEALTH
FUND
Medication errors and medical mistakes compromise quality of care.
Medication errors and medical mistakes also compromise quality of care.A 2002 Commonwealth Fund survey indicates that nearly one-fifth of sicker adults in the United States reported a serious medical mistake or medication error in the past two years (Chart II-5). A 2004 Fund survey found that 15 percent of contacted individuals had received incorrect test results or had experienced delays in receiving notification about abnormal results (Chart II-6). The United States compares unfavorably with other industrialized countries.
Communication affects quality of care.
Communication plays a critical role in quality of care. The 2004 Commonwealth Fund International Health Survey reveals missed opportunities by physicians to communicate effectively, involve patients in treatment decisions, and recognize patients' concerns or preferences (Schoen et al. 2004). In the United States, more than 50 percent of individuals did not feel that their doctor always spends adequate time with them. Approximately 40 percent of U.S. respondents indicated that their doctor does not always listen carefully and does notalways explain things clearly (Chart II-7).
31
THE COMMONWEALTH
FUND
The 2002 International Health Policy Survey examined the views of sicker adults and found that nearly one-third of those surveyed in the United States had in the past two years left a doctor's office without getting an important question answered. An even larger percentage of U.S respondents reported not adhering to a doctor's advice (Chart II-8). Research indicates that minorities face greater difficulty in communicating with physicians (Chart II-9).
Studies point to a link between patient-physician communication and a patient's acceptance of advice, adherence to treatment regimens, and satisfaction. Moreover, the quality of communication may also affect outcomes of care (Stewart 1995; Stewart et al. 2000). In an examination of interpersonal quality of care, middle-age adults gave lower rankings than seniors on the following measures: health providers listened carefully, health providers showed respect, and health providers spent enough time. When asked if the health provider always explained things clearly, only about 60 percent of seniors and middle-aged adults answered affirmatively (Chart II-10*).
* To access Leatherman and McCarthy's Chartbook on the Quality of Care for MedicareBeneficiaries, please visit http://www.cmwf.org/usr_doc/MedicareChartbk.pdf.
32
THE COMMONWEALTH
FUND
Expanding the use of information technology could facilitate communication and benefit both patients and physicians. The health care sector, however, has been slow to implement information technology, with the percentages of physician groups using electronic medical records remaining low(Chart II-11).
Physicians not as readily accessible as patients would hope.
In the 2004 Commonwealth Fund International Health Policy Survey, only a third of U.S. adults reported they were able to schedule a same-day appointment when sick or in need of medical attention (Chart II-12). Use of the emergency department (ED) as a substitute for regular physician care is a problem: 16 percent of U.S. respondents reported visiting the ED for a nonemergent condition (Chart II-12). Overall ED use in the United States was significant, with approximately one-third of respondents indicating they had used it in the past two years (Chart II-13).
33
THE COMMONWEALTH
FUND
Having a regular physician is important for quality.
When a patient builds a relationship with a physician, the result is enhanced care, increased trust, and patient adherence to treatment regimens (Parchman, M. and S. Burge 2004; Hall et al. 2001). Yet, only 37 percent of individuals in the United States surveyed in a 2004 Commonwealth Fund survey had a physician whom they had seen for more than five years(Chart II-14).
Debates continue regarding disclosure of quality information.
Around the world, there is debate about whether and how to disclose quality-of-care information to the public. The percentage of U.S. hospital CEOs who do not wish to disseminate certain information to the public varies according to the type of information under consideration (Chart II-15). Among consumers, it is apparent that more information is desired. The majority of Americans would like information pertaining to their health and the care they receive (Chart II-16).
34
THE COMMONWEALTH
FUND
Life expectancy and survival rates for certain medical conditions indicate need for improvement.
The United States spends more on health care than most countries, but its results lag behind.
– Five-year survival rates for kidney transplant and colorectal cancer in the United States are relatively low (Charts II-17 and II-18).
– The five-year survival rate for patients diagnosed with cancer varies based on race and ethnicity. Even greater variations exist based on socioeconomic status (Charts II-19 and II-20).
– The United States ranks below a number of other industrialized nations for life expectancy at birth and at age 65 (Charts II-21 and II-22).
35
THE COMMONWEALTH
FUND
Chart II-1. U.S. Adults Receive Half of Chart II-1. U.S. Adults Receive Half of Recommended Care, and Quality Varies Recommended Care, and Quality Varies
Significantly by Medical ConditionSignificantly by Medical Condition
Source: E. McGlynn et al., "The Quality of Health Care Delivered to Adults in the United States,"The New England Journal of Medicine (June 26, 2003): 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
36
THE COMMONWEALTH
FUND
Chart II-2. Provision of Appropriate Care Varies by Chart II-2. Provision of Appropriate Care Varies by StateState
Source: S. F. Jencks, E. D. Huff, and T. Cuerdon, "Change in the Quality of CareDelivered to Medicare Beneficiaries, 1998–1999 to 2000–2001," Journal of theAmerican Medical Association 289 (Jan. 15, 2003): 305–312.
Note: State ranking based on 22 Medicare performance measures.
Performance on Medicare Quality Indicators, 2000–2001Performance on Medicare Quality Indicators, 2000–2001
First
Third
Fourth
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
HI
37
THE COMMONWEALTH
FUND
Chart II-3. U.S. Performs Relatively WellChart II-3. U.S. Performs Relatively WellBut Emphasis on Prevention is Still LackingBut Emphasis on Prevention is Still Lacking
62 6155
50 49
0
25
50
75
Australia Canada New Zealand United
Kingdom
United States
Percent who DID NOT receive reminders for preventive care
Source: 2004 Commonwealth Fund International Health Policy Survey.
38
THE COMMONWEALTH
FUND
Chart II-4. Gaps Exist in Provision of Preventive Chart II-4. Gaps Exist in Provision of Preventive and Developmental Servicesand Developmental Services
Percent
Source: C. Bethell et al., Analysis of FAACT Surveys PHDS-Plus ofParents of Medicaid Children in Seven States. Unpublished data 2004.
50 48
69 7160
0
20
40
60
80
100
Parentalanticipatoryguidance
Parentalassessment forpsychosocial
issues
Parental screenfor tobacco and
substanceabuse
Family-centeredcare
Follow-up forchildren at risk
39
THE COMMONWEALTH
FUND
Percent of sicker adults reporting a serious error in past two years
Chart II-5. Medication or Medical MistakeChart II-5. Medication or Medical MistakeCaused Serious Health ConsequencesCaused Serious Health Consequences
in Past Two Yearsin Past Two Years
Source: The Commonwealth Fund 2002 International Health Policy Survey of Sicker Adults.
1315 14
9
18
0
10
20
30
Australia Canada New Zealand United
Kingdom
United States
40
THE COMMONWEALTH
FUND
Chart II-6. Incorrect Test Results andChart II-6. Incorrect Test Results andDelays in Notification of Abnormal Results Raise Delays in Notification of Abnormal Results Raise
Safety ConcernsSafety Concerns
8
14 1512
9
0
10
20
30
Australia Canada New Zealand United
K ingdom
United States
Percent of adults with test in past two years
Source: 2004 Commonwealth Fund International Health Policy Survey.
41
THE COMMONWEALTH
FUND
Chart II-7. Opportunities ExistChart II-7. Opportunities Existfor Enhanced Doctor–Patientfor Enhanced Doctor–Patient
Communication and InteractionsCommunication and Interactions
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.
42
THE COMMONWEALTH
FUND
Chart II-8. Significant Share of Adults Report Chart II-8. Significant Share of Adults Report Nonadherence, Questions Left UnansweredNonadherence, Questions Left Unanswered
In the past two years: AUS CAN NZ UK US
Left a doctor's office without getting important questions answered
21 25 20 19 31
Did not follow a doctor's advice
31 31 27 21 39
Source: 2002 Commonwealth Fund International Health Policy Survey.
Views of Sicker Adults*
* Sicker adults are individuals who met at least one of four criteria: reported their health asfair or poor; or in the past two years had a serious illness that required intensive medical care, major surgery, or hospitalization for something other than a normal birth.
43
THE COMMONWEALTH
FUND
19%16%
23%
33%
27%
0%
20%
40%
Total White African
American
Hispanic Asian
American
Chart II-9. Minorities Face Greater Difficulty in Chart II-9. Minorities Face Greater Difficulty in Communicating with PhysiciansCommunicating with Physicians
Base: Adults with health care visit in past two years.* Problems include understanding doctor, feeling doctor listened, had questions but did not ask.
Source: Commonwealth Fund 2001 Health Care Quality Survey.
Percent of adults with one or more communication problems*
44
THE COMMONWEALTH
FUND
Chart II-10. Interpersonal Quality of Care Lacking Chart II-10. Interpersonal Quality of Care Lacking for a Number of Patientsfor a Number of Patients
56 59 59
46
6559
66
54
0
20
40
60
80
100
Health providers
always listened
carefully
Health providers
always explained
things clearly
Health providers
always showed
respect
Health providers
always spent
enough time
Source: S. Leatherman and D. McCarthy, Quality of Health Care for Medicare Beneficiaries:A Chartbook, 2005, The Commonwealth Fund. www.cmwf.org; Medical Expenditure PanelSurvey (AHRQ 2005).
Percent of community-dwelling adults in 2001who visited doctor’s office in past year
Ages 45–64 Age 65+
45
THE COMMONWEALTH
FUND
87%
46%
57%
27%27%
59%
79%
14%
36%
68%
13%
25%
85%
61%
23%
35%37%
66%
84%77%
Electronic billing* Access to test results* Ordering of tests* Electronic medicalrecords*
All Physicians
1 Physician
2–9 Physicians
10–49 Physicians
50+ Physicians
Chart II-11. Physician Use of Electronic Chart II-11. Physician Use of Electronic Technology Could Be ExpandedTechnology Could Be Expanded
* p < .01, Cuzick's test for trend
Base: All respondents (N=1837)
Percent indicating "routine/occasional" use
Source: Commonwealth Fund 2003 National Survey of Physicians and Quality of Care.
46
THE COMMONWEALTH
FUND
Chart II-12. Substituting Emergency Department (ED) for Chart II-12. Substituting Emergency Department (ED) for Regular Care More Likely in U.S. and CanadaRegular Care More Likely in U.S. and Canada
54
9
18
60
7
41
6
33
16
27
0
25
50
75
Percent of adults who were sick or needed medical attention
AUS CAN NZ UK US
Same-day appointment available
Went to ED for condition that could have been treated by regular
physician if available
Source: 2004 Commonwealth Fund International Health Policy Survey.
AUS CAN NZ UK US
47
THE COMMONWEALTH
FUND
Chart II-13. Emergency Department Use Rates Chart II-13. Emergency Department Use Rates Higher in the U.S. and CanadaHigher in the U.S. and Canada
Percent with any visits
Source: 2004 Commonwealth Fund International Health Policy Survey.
29
3834
2927
0
25
50
Australia Canada NewZealand
UnitedKingdom
UnitedStates
48
THE COMMONWEALTH
FUND
Chart II-14. Continuity of Care with Chart II-14. Continuity of Care with Same Physician LackingSame Physician Lacking
Percent: AUS CAN NZ UK US
Has regular doctor/place94 95 97 99 91
2 years or less 22 20 21 18 29
3 to 5 years 22 21 20 17 25
More than 5 years 50 53 56 63 37
No regular doctor/place5 5 3 1 9
Source: 2004 Commonwealth Fund International Health Policy Survey.
49
THE COMMONWEALTH
FUND
Chart II-15. Type of Information Influences Hospital CEOs’ Chart II-15. Type of Information Influences Hospital CEOs’ Opinions Regarding Public DisseminationOpinions Regarding Public Dissemination
Source: 2003 Commonwealth Fund International Health Policy Survey of Hospital Executives.
Percent saying should NOT be released to the public:
AUS CAN NZ UK US
Mortality rates for specific conditions
34% 26% 18% 16% 31%
Frequency of specific procedures
16 5 4 13 15
Medical error rate 31 18 25 15 40
Patient satisfaction ratings 5 2 0 1 17
Average waiting times for elective procedures
6 1 0 1 29
Nosocomial infection rates 25 10 25 9 29
50
THE COMMONWEALTH
FUND
3445
28
5140
37
42
354840
0
25
50
75
100
Australia Canada New
Zealand
United
Kingdom
United
States
Percent lacking access to own medical records but would like access
Percent with access to own medical records
Chart II-16. Majority of Americans Want Chart II-16. Majority of Americans Want Information About Their Health and the Care Information About Their Health and the Care
They ReceiveThey Receive
Source: 2004 Commonwealth Fund International Health Policy Survey.
80 82 8070
88
51
THE COMMONWEALTH
FUND
Chart II-17. U.S. Performs Poorly on Kidney Chart II-17. U.S. Performs Poorly on Kidney Transplant Five-Year Relative Survival RateTransplant Five-Year Relative Survival Rate
100 104 104 106113
0
20
40
60
80
100
120
United
States
United
K ingdom
New
Zealand
Australia Canada
Standardized performance on quality indicator100 = Worst result; Higher score = Better results
Source: P. S. Hussey, G. F. Anderson, R. Osborn et al., "How Does the Qualityof Care Compare in Five Countries?" Health Affairs 23 (May/June 2004): 89–99.
52
THE COMMONWEALTH
FUND
Chart II-18. U.S. Lags on Colorectal Cancer Five-Chart II-18. U.S. Lags on Colorectal Cancer Five-Year Relative Survival RateYear Relative Survival Rate
100108 113 116
123
0
20
40
60
80
100
120
140
United
K ingdom
United
States
Canada Australia New
Zealand
Source: P. S. Hussey, G. F. Anderson, R. Osborn et al., "How Does the Qualityof Care Compare in Five Countries?" Health Affairs 23 (May/June 2004): 89–99.
Standardized performance on quality indicator100 = Worst result; Higher score = Better results
53
THE COMMONWEALTH
FUND
61 6258 60
49 5246
54
0
40
80
All races White Black Hispanic
Low poverty, <10% High poverty, 20%+
Percent of male patients diagnosed with cancer, 1988–1994
Chart II-19. Five-Year Survival Rates forChart II-19. Five-Year Survival Rates forCancer Patients Vary by Race/EthnicityCancer Patients Vary by Race/Ethnicity
and Census Poverty Tractand Census Poverty Tract
Source: G. Singh et al., "Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality,Stage, Treatment and Survival, 1975–1999," NCI, 2003. Figures 6.3 and 6.4.
54
THE COMMONWEALTH
FUND
63 6359
65
53 5548
60
0
40
80
All races White Black Hispanic
Low poverty, <10% High poverty, 20%+
Percent of female patients diagnosed with cancer, 1988–1994
Chart II-20. Five-Year Survival Rates for Cancer Chart II-20. Five-Year Survival Rates for Cancer Patients Vary by Race/EthnicityPatients Vary by Race/Ethnicity
and Census Poverty Tractand Census Poverty Tract
Source: G. Singh et al., "Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality,Stage, Treatment and Survival, 1975–1999," NCI, 2003. Figures 6.3 and 6.4.
55
THE COMMONWEALTH
FUND
Chart II-21. Life Expectancy at BirthChart II-21. Life Expectancy at BirthLower in the United StatesLower in the United States
82.9 81.1 80.7 79.98181.382.182.885.3
74.576.276.375.575.577.277.875.878.4
0
10
20
30
40
50
60
70
80
90
Female Male
Source: OECD Health Data, 2005.
56
THE COMMONWEALTH
FUND
Chart II-22. United States Performs Poorly on Chart II-22. United States Performs Poorly on Life Expectancy at Age 65Life Expectancy at Age 65
19.6 19.119.519.62020.62121.323
16.116.61616.116.717.217.616.918
0
5
10
15
20
25
Female Male
Source: OECD Health Data, 2005.
57
THE COMMONWEALTH
FUND
III. Need for Greater EfficiencyIII. Need for Greater Efficiency
After a period of relatively stable growth in the 1990s, health care spending has exploded in recent years. Health care costs are concentrated among the sickest and most vulnerable Americans and are borne by those with private as well as public coverage.
– In 2002, U.S. health expenditures totaled 14.6 percent of gross domestic product, substantially higher than other developed nations. This percentage is projected to rise in the next decade (Charts III-1 and III-2).
– Ten percent of patients account for 69 percent of health expenditures (Chart III-3).
– Closer examination of the continued acceleration of health care spending indicates that private insurance premiums have historically outpaced Medicare spending per beneficiary (Chart III-4).
58
THE COMMONWEALTH
FUND
The United States far outpaces other countries in health care spending per capita (Chart III-5). Per capita out-of-pocket health spending in 2002 was more than double the OECD median (Chart III-6). Yet, the United States does not consistently use more services. In international comparisons of hospital discharges and average annual physician visits per capita, the United States sits on the lower end of the spectrum (Charts III-7 and III-8). Still, U.S. hospital expenditures exceed those in France, Canada, and Australia (Chart III-9), and use of expensive specialty services is much higher (Chart III-10).
Administrative costs are rising rapidly.
Health care coordination and administration are two areas that may greatly benefit from initiatives to raise efficiency. Growth in administrative costs has exceeded growth in national health expenditures (Chart III-11).
59
THE COMMONWEALTH
FUND
Enhancements in care coordination could foster cost savings.
A study examining elderly adults hospitalized for heart failure determined that transitional care provided by an advanced practice nurse reduced rehospitalization rates and lowered overall health care costs. Through discharge planning and home follow-up visits, the advanced practice nurse provided needs assessment, care planning, patient education, and therapeutic support. The average cost of care for the intervention group was 39 percent lower than for the group receiving usual care (Chart III-12).
Lack of care coordination can lead to the unavailability of test results or records at the time of the patient's appointment; duplication of testing; or provision of conflicting information by the patient's various physicians. The 2004 Commonwealth Fund International Health Policy Survey found that 31 percent of those surveyed in the United States had experienced at least one of the aforementioned issues (Chart III-13). Individuals lacking insurance are more likely to experience a care coordination problem (Chart III-14).
60
THE COMMONWEALTH
FUND
Substantial variations indicate a need for standardization of practices based on individual patient characteristics and conditions, not on geographic location.
Standardization of practices can create more effective care while decreasing costs. Currently, there are substantial variations within the health care system, including quantity of services and prices.
– Across large Pennsylvania hospitals, charges for medical management of acute myocardial infarction vary eightfold (Chart III-15).
– Medicare spending varies across the states; higher Medicare spending per beneficiary does not necessarily correlate with higher-quality care (Chart III-16).
– Quality and cost vary greatly across hospitals (Chart III-17).
– Drug prices are between 34 to 59 percent lower in Canada, France, and the United Kingdom than in the United States (Chart III-18).
– Doctors who practice more evidence-based medicine can be the ones whose costs per case are lowest, but they can also be the highest (Chart III-19). Strategies are needed to foster high-quality, high-efficiency practices.
61
THE COMMONWEALTH
FUND
Chart III-1. U.S. Spends Greater Percentage of Chart III-1. U.S. Spends Greater Percentage of GDP on Health Care Than Other NationsGDP on Health Care Than Other Nations
14.6
10.99.7 9.6 9.1 8.5 8.5
7.8 7.7
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
United
States
Germany France Canada Australia
(2001)
OECD
Median
New
Zealand
J apan
(2001)
United
Kingdom
Source: G. F. Anderson and P. S. Hussey, Multinational Comparisons of HealthSystems Data 2004, The Commonwealth Fund, October 2004. OECD data.
Percent of gross domestic product (GDP) spent on health care, 2002
THE COMMONWEALTH
FUND
62
THE COMMONWEALTH
FUND
1918
1616151514
13131313131313131313121111
0
5
10
15
20
Projected
Chart III-2. U.S. Health ExpendituresChart III-2. U.S. Health Expendituresas Share of GDP Expected to Riseas Share of GDP Expected to Rise
Through Next DecadeThrough Next DecadeExpenditures as percent of gross domestic product (GDP)
Source: Center for Medicare and Medicaid Services, Office of the Actuary, 1998–2003 from CMS Health Accounts data file nhegdp03.zip available at http://www.cms.hhs.gov/statistics/nhe/default.asp; 2004–2014 published in Heffler et al., "U.S. Health Spending Projections for 2004–2014," Health Affairs Web Exclusive (February 23, 2005): W5-74–W5-85.
63
THE COMMONWEALTH
FUND
Chart III-3. Health Care CostsChart III-3. Health Care CostsConcentrated in Sick FewConcentrated in Sick Few
0%
10%
20%30%
40%
50%
60%
70%80%
90%
100%
U.S. population Health expenditures
1%5%
10%
55%
69%
27%
Source: A. C. Monheit, "Persistence in Health Expenditures in the Short Run:Prevalence and Consequences," Medical Care 41, supplement 7 (2003): III53–III64.
Distribution of health expenditures for the U.S. population,Distribution of health expenditures for the U.S. population,by magnitude of expenditure, 1997by magnitude of expenditure, 1997
50%
97%
$27,914
$7,995
$4,115
$351
Expenditure Threshold
(1997 Dollars)
64
THE COMMONWEALTH
FUND
Chart III-4. Private Insurance PremiumsChart III-4. Private Insurance PremiumsHave Historically Outpaced Medicare Spending Have Historically Outpaced Medicare Spending
per Beneficiaryper Beneficiary
9.0
5.9
10.18.8
9.610.7
0
2
4
6
8
10
12
1969–2003 1999–2003
Medicare Private health insurance FEHBP*
Percent annual growth in per-enrollee spending
Source: Analysis by Office of the Actuary, Centers for Medicare and Medicaid Services, January 2005.
* FEHBP estimates are for 1969–2002 and 1999–2002 from Levit et al.,“Health Spending Rebound Continues in 2002,” Health Affairs 23 (Jan/Feb 2004).
65
THE COMMONWEALTH
FUND
Chart III-5. Health Care Spending Per Capita in Chart III-5. Health Care Spending Per Capita in 2002 Illustrates Higher U.S. Spending2002 Illustrates Higher U.S. Spending
Adjusted for differences in cost of livingAdjusted for differences in cost of living
$553
5,267
$3,446
$2,931 $2,817$2,736$2,643$2,517 $2,504
$2,193 $2,160 $2,077$1,857
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Source: G. F. Anderson et al., "Health Spending in the United States and the Rest of the Industrialized World," Health Affairs 24 (July/August 2005): 903. OECD Health Data.
66
THE COMMONWEALTH
FUND
Chart III-6. Out-of-Pocket Health Care Spending Per Chart III-6. Out-of-Pocket Health Care Spending Per Capita in 2002 Highest in United States Capita in 2002 Highest in United States
Adjusted for differences in cost of livingAdjusted for differences in cost of living
$737
$483$445
$347 $342$298 $292 $288
$268 $266
$0
$100
$200
$300
$400
$500
$600
$700
$800
United States
Australia (2001)
Canada
OECD M
edian
J apan (2001)
New
Zealand
Germ
any
Mexico (2001)
France
Netherlands
Source: OECD Health Data.
67
THE COMMONWEALTH
FUND
252 247
201
159 156
11298 91
206
0
50
100
150
200
250
300
France
(2001)
United
Kingdom
New
Zealand
Germany
(2001)
OECD
Median
Australia J apan United
States
Canada
(2001)
Chart III-7. United States on Lower End of Spectrum for Chart III-7. United States on Lower End of Spectrum for Hospital Discharges per 1,000 Population in 2002Hospital Discharges per 1,000 Population in 2002
Source: OECD Health Data, 2004, from G. F. Anderson et al., "MultinationalComparisons of Health Systems Data, 2004" (forthcoming).
68
THE COMMONWEALTH
FUND
Chart III-8. United States on Lower End of Spectrum for Chart III-8. United States on Lower End of Spectrum for Average Annual Number ofAverage Annual Number ofPhysician Visits Per CapitaPhysician Visits Per Capita
2.52.9
3.64.4
4.96.26.26.2
6.97.3
14.5
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
J apa
n (200
1)
Ger
many
(200
0)
Fran
ce (2
001)
Austral
ia (2
002)
Canad
a (2
001)
OECD M
edian
Uni
ted K
ingd
om (2
000)
New
Zea
land
(200
1)
Uni
ted S
tate
s (2
001)
Swede
n (200
1)
Mexi
co (2
002)
Source: OECD Health Data.
69
THE COMMONWEALTH
FUND
Chart III-9. Per-Day Hospital Expenditures High in Chart III-9. Per-Day Hospital Expenditures High in the United Statesthe United States
Adjusted for differences in cost of livingAdjusted for differences in cost of living
$2,434
$902 $870 $848
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
United States
(2002)
France (2001) Canada (2001) Australia (2001)
Source: OECD Health Data.
70
THE COMMONWEALTH
FUND
416
158 157130
94 86 73
0
100
200
300
400
500
United
States
Canada
(2001)
France
(2001)
Australia OECD
Median
New
Zealand
United
Kingdom
Chart III-10. United States UsesChart III-10. United States UsesMore Expensive Specialty ServicesMore Expensive Specialty Services
Source: OECD Health Data 2004, from G. F. Anderson et al., "MultinationalComparisons of Health Systems Data, 2004" (forthcoming).
Percutaneous transluminal coronary angioplasty (PTCA) interventions per 100,000 population in 2002
71
THE COMMONWEALTH
FUND
Chart III-11. Administrative Cost Growth Outpaces Chart III-11. Administrative Cost Growth Outpaces Total Medical Expenditure GrowthTotal Medical Expenditure Growth
6.2
9.78.5
12.5
9.3
16.3
7.7
13.2
0
5
10
15
20
National health expenditure Administrative costs of private
and public insurance
Annual growth 1997–2000
Annual growth 2000–2001
Annual growth 2001–2002
Annual growth 2002–2003
* Administrative costs totaled $119.7 billion in 2003, nearly double that of 1997.
Source: Smith et al., "Health Spending Growth Slows in 2003," Health Affairs 24 (Jan/Feb 2005).
Percent
72
THE COMMONWEALTH
FUND
Chart III-12. Transitional Care ReducesChart III-12. Transitional 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
73
THE COMMONWEALTH
FUND
Chart III-13. Care Coordination Concerns Chart III-13. Care Coordination Concerns AboundAbound
Percent saying in the pasttwo years:
AUS CAN NZ UK US
Test results or records not available at time of appointment 12 14 13 13 17
Duplicate tests: doctor ordered test that had already been done 7 6 7 4 14
Received conflicting information from different doctors 18 14 14 14 18
Percent who experienced at least one of the above 28 26 25 24 31
Base: Have seen a doctor in past two years
Source: 2004 Commonwealth Fund International Health Policy Survey.
74
THE COMMONWEALTH
FUND
Chart III-14. Uninsured in U.S. at Highest Risk for Chart III-14. Uninsured in U.S. at Highest Risk for Care Coordination ProblemCare Coordination Problem
3026 26 26
3328
44
0
20
40
60
Australia Canada New Zealand UnitedKingdom
Total Insured allyear
Uninsuredanytime
Percent ages 19–64 reporting any of three coordination problems*
Source: 2004 Commonwealth Fund International Health Policy Survey.
*Coordination problems include duplication of tests, conflicting views,and medical record not available at time of appointment.
United States
75
THE COMMONWEALTH
FUND
Chart III-15. Charges for Medical Management of Chart III-15. Charges for Medical Management of Acute Myocardial Infarction Vary Eightfold Across Acute Myocardial Infarction Vary Eightfold Across
Large Pennsylvania HospitalsLarge Pennsylvania Hospitals
* This hospital demonstrated significantly lower than expected in-hospital mortality rates. Note: Hospital charge equals patient total charge excluding professional fees; all hospitals shown provided advanced cardiac services (angioplasty/stent procedures), had >100 cases, and <5% of cases transferred to another acute care facility. Source: Pennsylvania Health Care Cost Containment Council, Hospital Performance Results, Hospital discharges between January 1, 2003 and December 31, 2003, www.phc4.org.
88,457
64,627
43,636
10,59214,020 14,871
18,596 19,29424,012
29,672
$0
$20,000
$40,000
$60,000
$80,000
$100,000
Lowest mortality hospital
$21,846*
76
THE COMMONWEALTH
FUND
Chart III-16. Quality and Medicare Spending Vary Chart III-16. Quality and Medicare Spending Vary Across States, 2000–2001Across States, 2000–2001
Quality Expressed by Percent of Beneficiaries with Atrial FibrillationQuality Expressed by Percent of Beneficiaries with Atrial Fibrillation
Sources: K. Baicker and A. Chandra, "Medicare Spending, The Physician Workforce, and Beneficiaries' Quality of Care," Health Affairs Web Exclusive (April 7, 2004).
77
THE COMMONWEALTH
FUND
Chart III-17. Cost and Quality Vary WidelyChart III-17. Cost and Quality Vary WidelyAcross U.S. HospitalsAcross U.S. Hospitals
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, "The Business Case for Safety and Quality: What Can Our Databases Tell Us," 5th Annual NPSF Patient Safety Congress, March 15, 2003.
78
THE COMMONWEALTH
FUND
Chart III-18. Pharmaceutical Prices in U.S. Chart III-18. Pharmaceutical Prices in U.S. Exceed Those in Other CountriesExceed Those in Other Countries
Source: G. F. Anderson, D. Shea, P. S. Hussey et al., "Doughnut Holesand Price Controls," Health Affairs Web Exclusive (July 21, 2004).
100
4841
53
100
6052
66
0
20
40
60
80
100
120
United S tates Canada F ranc e United K ingdom
N o U .S. disc ount 20% U .S. disc ountPrice index
Note: Analysis of IMS health data.
Relative Prices of Thirty Pharmaceuticals in Four Countries, 2003
79
THE COMMONWEALTH
FUND
Chart III-19. High Longitudinal EfficiencyChart III-19. High Longitudinal Efficiencyand Quality Are Compatibleand Quality Are Compatible
(Applies to selections of providers and treatment options)(Applies to selections of providers and treatment options)
Higher LowerMD Longitudinal Efficiency Index
(total cost per case mix-adjusted treatment episode)
MD
Qu
ali
ty I
nd
ex
(ou
tco
me
s o
r %
ad
he
ren
ce
to
EB
M)
High QualityLow TCO(Dream Suppliers)
High QualityHigh TCO
L
ow
er
Hig
he
r
50th %ile
50th %ile
TCO is total cost of ownership. It refers to the average stream of total health care spending over the course of alongitudinal episode of care, adjusted for case mix/severity of illness incurred for a particular provider's patients.
Source: A. Milstein, "Restorers, Skin-grafters & Calibrators: A Five-Year Forecast for Large Employer Cost Sharing,"data from Regence Blue Shield; Health System Change Patient Cost Sharing Conference, 12/3/2003.
Low QualityHigh TCO(Nightmare Suppliers)
Low QualityLow TCO
80
THE COMMONWEALTH
FUND
Although there are numerous challenges facing the U.S. health care system, transformation is possible. In the minds of health care opinion leaders,* enhanced performance is not unrealistic, and viable policies for improving access, quality, and efficiency are attainable. Currently, 18 percent of the under-65 population is without health insurance. According to a Commonwealth Fund Health Care Opinion Leaders survey released in March 2005, the proportion of uninsured can and should be reduced by more than half in 10 years (Chart IV-1).
Respondents to the survey believe that health expenditures will need to increase somewhat as a percentage of GDP (Chart IV-1). But they also believe that there are effective ways to cut health care costs. According to a survey released in May 2005, these leaders consider pay-for-performance to be the most effective means to reduce health care costs.
Conclusion. The Time Is RipeConclusion. The Time Is Ripefor Improvementfor Improvement
* Health care opinion leaders answering the Fund's survey include widely recognizedU.S. experts in health care policy, finance, and delivery with a variety of perspectivesand expertise.
81
THE COMMONWEALTH
FUND
In addition, a majority of respondents believe enhanced disease management and primary care case management would effectively reduce unnecessary utilization of health care services. Respondents were also enthusiastic about use of evidence-based guidelines, and nearly half rated expanding the use of information technology as an extremely or very effective means of controlling use of unnecessary services (Chart IV-2).
Promising strategies for improving affordability and achieving savings also include the following:
– Management of high-cost care
– Selection of medical home and improved access to primary care and preventive services
– Better information on provider quality and total costs of care
– Development of networks of high-performing providers under Medicare, Medicaid, and private insurance
– Limits on family premium and out-of-pocket costs as a percent of income (e.g., 5 percent of income for low-income individuals)
– Expanded group coverage and reinsurance
82
THE COMMONWEALTH
FUND
Medicare, which comprised one-fifth of all personal health care spending in 2003 (MedPAC 2004), is a major payer and therefore an important driver of change. The Centers for Medicare and Medicaid Services (CMS) conducts and sponsors demonstration projects in order to evaluate the effect of new interventions and to inform policy decisions. Large majorities of respondents who participated in an online survey of U.S. health care experts favor leveraging Medicare to speed the adoption of electronic medical records and health information technology (Chart IV-3). Innovations in the private sector are also important for promoting high-quality, high-efficiency, and cost-effective care.
The Commission on a High Performance Health System will seek opportunities to change the delivery and financing of health care to improve system performance and will identify public and private policies and practices that would lead to those improvements. It will explore mechanisms for financing improved health insurance coverage and investments in the nation's capacity for quality improvement, including reinvesting savings from efficiency gains.
83
THE COMMONWEALTH
FUND
Chart IV-1. Transformation Is PossibleChart IV-1. Transformation Is Possible
18% 15%
63%
9%8%16%
65%
0%
20%
40%
60%
80%
Proportion of under-65population that has no
health insurance
Total cost of health careas a percentage of GDP
Percent of under-65population with
employer-providedinsurance
Maximum % of income aconsumer should spend
for out-of-pocketexpenses and
premiums
Current Goal
Source: Commonwealth Fund Health Care Opinion Leaders Survey, February 2005.
"What you would see as both an achievable anda desirable target or goal for policy action for the next 10 years?"
Note: Goal percentages represent median responses.
Asked as a current target, not a ten-year
goal
84
THE COMMONWEALTH
FUND
Chart IV-2. Health Care Leaders: Pay-for-PerformanceChart IV-2. Health Care Leaders: Pay-for-PerformanceIs Most Effective Way to Reduce Health Care CostsIs Most Effective Way to Reduce Health Care Costs
31%
44%
46%
52%
56%
57%
Have patients pay a substantially higher share of theirhealth care costs
Have all payers, including private insurers, Medicare,and Medicaid, adopt common payment methods and
rates
Expand the use of information technology
Use evidence-based guidelines to determine when atest or procedure should be done
Improve disease management and primary care casemanagement
Reward more efficient and high-quality medical-careproviders
Source: Commonwealth Fund Health Care Opinion Leaders Survey, April 2005.
"How effective do you think each of these possible actionswould be to reduce health care costs?"
(Percent saying extremely or very effective)
85
THE COMMONWEALTH
FUND
Chart IV-3. Health Policy Experts Suggest Various Chart IV-3. Health Policy Experts Suggest Various Changes to MedicareChanges to Medicare
67%
67%
67%
67%
87%
89%
Eliminating the two-year waiting period for coverageof the disabled
Having Medicare offer its own comprehensive benefitpackage as an alternative to Medigap or Medicare
Advantage
Raising taxes to ensure Medicare’s long-termsolvency
Allowing those under age 65 to contribute to aMedicare savings account
Using Medicare’s leverage to reward providers forperformance on quality and efficiency
Using Medicare leverage to accelerate adoption ofelectronic medical records and health information
technology
Source: Commonwealth Fund Health Care Opinion Leaders Survey, July 2005.
"Do you favor or oppose changing Medicare in the following ways?"(Percent who favor…)
86
THE COMMONWEALTH
FUND
ReferencesReferences
Baile, W. and J. Aaron. “Patient–Physician Communication in Oncology: Past, Present, and Future.”Current Opinion in Oncology. 17(4). (July 2005): 331.
Collins, S. et al. “Opinion: Proposals for Health Policy.” Inquiry. 42. (Spring 2005): 6.
Cutler, D. and M. McClellan. “Is Technological Change in Medicine Worth It?” Health Affairs. 20(5). (Sept/Oct 2001): 11.
Davis, K. et al. Health and Productivity Among U.S. Workers. (New York, The Commonwealth Fund, August 2005).
Davis, K. et al. Mirror, Mirror on the Wall: Looking at the Quality of American Health Care Through the Patient’s Lens.(New York, The Commonwealth Fund, Jan. 2004).
Fisher, E. et al. “The Implications of Regional Variations in Medicare Spending: Part I. The Context, Quality, and Accessibility of Care.” Annals of Internal Medicine. 138. (Feb 18, 2003): 273.
Gilmer, T. and R. Kronick. “It's the Premiums, Stupid: Projections of the Uninsured Through 2013.” Health AffairsWeb Exclusive. April 5, 2005.
Glied, S. and S. Little. “The Uninsured and the Benefits of Medical Progress.” Health Affairs. 22(4). (July/Aug 2003): 210.
Hall, M. et al. “Trust in Physicians and Medical Institutions: What Is It, Can It Be Measured, and Does It Matter?”The Milbank Quarterly. 79(4). (2001): 613.
87
THE COMMONWEALTH
FUND
References (cont.)References (cont.)
Institute of Medicine. Hidden Costs, Value Lost: Uninsurance in America. (Washington, DC: National AcademiesPress, 2003).
Jencks, S., Huff, E. and T. Cuerdon. "Change in the Quality of Care Delivered to Medicare Beneficiaries,1998–1999 to 2000–2001. JAMA. 289(3). (January 15, 2005): 305.
Kohn, L., Corrigan, J. and M. Donaldson (eds). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
Leatherman, S. and D. McCarthy. Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005.The Commonwealth Fund.
MedPAC. June 2004. "National Health Care and Medicare Spending." In A Data Book: Health Care Spendingand the Medicare Program. Washington, DC: MedPAC. www.medpac.gov.
McGlynn et al. "The Quality of Health Care Delivered to Adults in the United States." The New England Journalof Medicine. (June 26, 2003): 2635.
Parchman, M. and S. Burge. "The Patient-Physician Relationship, Primary Care Attributes, and Preventive Services." Family Medicine. 36(1). (January 2004): 22.
Reinhardt, U., Hussey, P. and G. Anderson. "U.S. Health Care Spending in an International Context." HealthAffairs. 23(3). (May/June 2004): 10.
88
THE COMMONWEALTH
FUND
References (cont.)References (cont.)
Schoen, C. et al. "Insured But Not Protected: How Many Adults Are Underinsured?" Health Affairs Web Exclusive.June 14, 2005.
Schoen, C. et al. "Primary Care and Health System Performance: Adults' Experiences in Five Countries." Health Affairs Web Exclusive. October 28, 2004.
Stewart, M. et al. "The Influence of Older Patient-Physician Communication on Health and Health-Related Outcomes. Clinical Geriatric Medicine. 16(1). (2000): 25.
Stewart, M. "Effective Physician-Patient Communication and Health Outcomes: A Review." CMAJ. 152(9):1,423.
U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2004 . (Washington, DC: U.S. Government Printing Office, 2005).
89
THE COMMONWEALTH
FUND
Visit the Fund atVisit the Fund at www.cmwf.orgwww.cmwf.org
Publications:• Chartbooks on quality of care• International surveys (annual)• Other publications on coverage,
access, and quality