Glenn Steele: Achieving a high performance health system
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Transcript of Glenn Steele: Achieving a high performance health system
THE COMMONWEALTH
FUND
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
2
THE COMMONWEALTH
FUND
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?
3
THE COMMONWEALTH
FUND
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.
4
THE COMMONWEALTH
FUND
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
5
THE COMMONWEALTH
FUND
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
6
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
7
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
8
THE COMMONWEALTH
FUND
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
9
THE COMMONWEALTH
FUND
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
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
10
THE COMMONWEALTH
FUND
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
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
11
THE COMMONWEALTH
FUND
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
12
THE COMMONWEALTH
FUND
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
FUND
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
13
EQUITY: COORDINATED AND EFFICIENT CARE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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THE COMMONWEALTH
FUND
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
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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
15
THE COMMONWEALTH
FUND
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
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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
16
THE COMMONWEALTH
FUND
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
17
THE COMMONWEALTH
FUND
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
18
THE COMMONWEALTH
FUND
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
FUND
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
20
THE COMMONWEALTH
FUND
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
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
2001 2006
United States
21
THE COMMONWEALTH
FUND
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*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
22
THE COMMONWEALTH
FUND
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
23
THE COMMONWEALTH
FUND
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
24
THE COMMONWEALTH
FUND
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.
25
THE COMMONWEALTH
FUND
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.
26
THE COMMONWEALTH
FUND
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.
27
THE COMMONWEALTH
FUND
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.
28
THE COMMONWEALTH
FUND
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.
29
THE COMMONWEALTH
FUND
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.
30
THE COMMONWEALTH
FUND
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
31
THE COMMONWEALTH
FUND
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