Glenn Steele: Achieving a high performance health system
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    Glenn Steele: Achieving a high performance health system Glenn Steele: Achieving a high performance health system Presentation Transcript

    • THECOMMONWEALTH FUND Achieving a High Performance Health System Glenn D. Steele Jr., MD Geisinger Health SystemCommission on a High Performance Health System Nuffield Trust Annual Health Policy Meeting March 24, 2009
    • 2 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? THE COMMONWEALTH FUND
    • 3 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. THE COMMONWEALTH FUND
    • 4 Goals for a High Performance Health SystemHIGH QUALITY ACCESS AND CARE EQUITY FOR ALL LONG, HEALTHY, AND PRODUCTIVE LIVES SYSTEM AND EFFICIENT WORKFORCE CARE INNOVATION AND IMPROVEMENT THE COMMONWEALTH FUND
    • 5 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 THE COMMONWEALTH FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5
    • National Scorecard on 6 Health System Performance 75 2006 Revised Healthy Lives 72 2008 72 Quality 71 67 Access 58 52 Efficiency 53 70 Equity 71 67OVERALL SCORE 65 0 100 THE COMMONWEALTH FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • 7 Mirror Mirror: US Falls Behind Country Rankings 1-2.66 2.67-4.33 4.33-6.0 NEW UNITED UNITED AUSTRALIA CANADA GERMANY ZEALAND KINGDOM STATES 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 $6,102* 2003 data THE COMMONWEALTHSource: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, Mirror, FUNDMirror on the Wall: An International Update on the Comparative Performance of American Health Care, TheCommonwealth Fund, May 2007
    • International Comparison of Spending 8 on Health, 1980–2006 Average spending on health Total expenditures on health as per capita ($US PPP*) percent of GDP $7,000 16 United States Germany $6,000 Canada 14 Netherlands France 12 $5,000 Australia United Kingdom 10 $4,000 8 $3,000 6 United States $2,000 Germany 4 Netherlands Canada $1,000 France 2 Australia United Kingdom $0 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 80 82 84 86 88 90 92 94 96 98 00 02 04 06 19 19 19 19 19 19 19 19 19 19 20 20 20 20 19 19 19 19 19 19 19 19 19 19 20 20 20 20 THE COMMONWEALTH FUND* PPP=Purchasing Power Parity.Source: OECD Health Data 2008, Version 06/2008.
    • HEALTHY LIVES 9 Mortality Amenable to Health CareDeaths per 100,000 population*150 1997/98 2002/03 134 130 128 116 115 113 115 109 106 99 97 97100 88 89 89 88 81 84 76 103 103 104 110 50 93 96 101 84 84 90 77 80 82 82 71 71 74 74 65 0 lia ly nd ria y k ce n d m l e es d en s da ay n ga an ec ar nd an ai pa an It a do ra an at la st rw ed na r tu Sp nm e m nl al la Ja Ir e st St Au ng Gr Fr No Ca Sw r Fi Ze er Po Au Ge De d Ki th ite w Ne d Ne Un ite Un* 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 THEAffairs, January/February 2008, 27(1):58–71 COMMONWEALTH FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • QUALITY: EFFECTIVE CARE 10 Receipt of Recommended Screening and Preventive Care for Adults Percent of adults (ages 18+) who received all recommended screening and preventive care within a specific time frame given their age and sex* U.S. Average 2002 49 2005 50 U.S. Variation 2005 400% + of poverty 58 200% –399% of poverty 47 <200% of poverty 39 Insured all year 53 Uninsured part year 46 Uninsured all year 32 0 20 40 60 80 100* 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. THE COMMONWEALTHData: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey. FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • 11 Hospital Standardized Mortality Ratios Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors. Medicare national average for 2000 = 100 Ratio of actual to expected deaths in each decile (x 100) 140 2000-2002 2003-2005 118 120 112 103 106 106 105 97 100 100 93 94 91 94 87 90 85 84 84 81 80 76 70 60 40 20 0 1 2 3 4 5 6 7 8 9 10 Decile of hospitals ranked by actual to expected deaths ratiosSee Technical Appendix for methodology. THEData: B. Jarman analysis of Medicare discharges from 2000 to 2002 and from 2003 to 2005 for conditions leading to 80 COMMONWEALTH percent ofall hospital deaths. FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, July 2008
    • 12 Any Medical, Medication, or Lab Error in Past Two Years Percent any error 50 All Adults 2+ Chronic Conditions 32 28 26 25 24 25 22 20 20 17 16 16 14 13 12 0 AUS CAN GER NETH NZ UK US THE COMMONWEALTHNote: Errors include medical mistake, wrong dose/medication, or lab test error. FUNDSource: 2007 Commonwealth Fund International Health Policy Survey
    • EQUITY: COORDINATED AND EFFICIENT CARE 13 Ambulatory Care–Sensitive Hospital Admissions, by Race/Ethnicity and Patient Income Area, 2004/2005* Adjusted rate per 100,000 population Heart failure Diabetes** Pediatric asthma1000 904 667 554 520 500 444 392 374 390 240 178 173 144 98 110 NA 0 i te k nic + 0 e k 0 e k 0 ac 00 ,00 hit ac nic 0+ , 00 hit ac nic 0+ , 00 Wh Bl spa 5,0 25 W Bl sp a 5,0 0 25 W Bl sp a 5,0 0 25 Hi $4 <$ Hi $4 <$ Hi $4 <$* 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. THEData: Race/ethnicity—Healthcare Cost and Utilization Project, State Inpatient Databases and National Hospital Discharge Survey COMMONWEALTH(AHRQ 2007); Income area—HCUP, Nationwide Inpatient Sample (AHRQ 2007, retrieved from HCUPnet at http://hcupnet.ahrq.gov). FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 13
    • EFFICIENCY 14 Medicare Hospital 30-Day Readmission Rates Percent of Medicare beneficiaries admitted for one of 31 select conditions who are readmitted within 30 days following discharge* 30 21 20 19 20 20 18 18 16 16 15 14 10 0 2003 2005 10th 25th 75th 90th 10th 25th 75th 90th U.S. Mean Hospital Percentiles, 2005 State Percentiles, 2005* See Appendix B for list of conditions used in the analysis. THEData: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% COMMONWEALTH FUNDInpatient Data.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • ACCESS 15Uninsured and Under-insured Adults, 2007 Compared with 2003 Percent of adults (ages 19–64) who are uninsured or underinsured 100 Underinsured* 72 Uninsured during year 75 68 19 24 50 42 35 14 27 9 25 49 48 17 11 26 28 4 13 16 0 2003 2007 2003 2007 2003 2007 Total Under 200% of poverty 200% of poverty or more* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income, THEor 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. COMMONWEALTHData: 2003 and 2007 Commonwealth Fund Biennial Health Insurance Survey. FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • 16 Access Problems Because of Costs, 2007 Percent of adults who had any of three access problems* in past year because of costs 50 37 25 26 25 21 12 8 5 0 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 didnot fill Rx or skipped doses because of cost. THEAUS=Australia; CAN=Canada; GER=Germany; NET=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States. COMMONWEALTH FUNDData: 2004 and 2007 Commonwealth Fund International Health Policy Surveys.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • 17 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 THE COMMONWEALTH FUND2005 Commonwealth Fund International Health Policy Survey of Sicker Adults
    • 18 Primary Care Doctors in U.S. Less Likely to Have Arrangement for Patients’ After-Hours Care to See Nurse/Doctor Percent 100 95 90 87 81 76 75 47 50 40 25 0 NETH NZ UK AUS GER CAN US THE COMMONWEALTHSource 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. (Schoen et al. FUND“On the Front Lines of Care…” Health Affairs, Nov. 2, 2006.
    • 19Physicians in U.S. Less Likely to Receive Incentives for QualityPercent of Physicians Reporting anyFinancial Incentive for Quality ofCare*100 95 79 75 72 58 50 43 41 30 25 0 UK NZ AUS NETH GER CAN US* Receive or have potential to receive payment for: clinical care targets, high patient ratings, THE COMMONWEALTHmanaging chronic disease/complex needs, preventive care, or QI activities. FUNDSource: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
    • EFFICIENCY 20 Physicians’ Use of Electronic Health Records Percent of primary care physicians using electronic medical records 2001 2006 98 100 92 89 79 75 50 42 28 23 25 17 0 NETH NZ UK AUS GER CAN United States International ComparisonAUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom. THE COMMONWEALTHData: 2001 and 2006 Commonwealth Fund International Health Policy Survey of Physicians. FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • EFFICIENCY 21 Percentage of National Health Expenditures Spent on Insurance Administration, 2005 Net costs of health insurance administration as percent of national health expenditures 10 8 7.5 6.9 6 5.6 4.8 4.2 4.3 3.9 4 3.3 2.8 2.3 1.9 2 0 nd an ia m tri a a s nd y ce * la ap tr al do s nad nd la an an t es Fi n J s in g Au Ca rl a e r er m Fr ta Au K he itz G d S d et Sw ite ite N Un Una 2004 b 2001* Includes claims administration, underwriting, marketing, profits, and other administrative costs;based on premiums minus claims expenses for private insurance. THE COMMONWEALTHData: OECD Health Data 2007, Version 10/2007. FUNDSource: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • 22 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 THE COMMONWEALTH FUND
    • 23 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 collaborationSource: Commission on a High Performance Health System, A High Performance Health THE COMMONWEALTHSystem for the United States: An Ambitious Agenda for the Next President, The FUNDCommonwealth Fund, November 2007
    • 24Total National Health Expenditures (NHE), 2009–2020 Current Projection and Alternative Scenarios NHE in trillions $6 Current projection (6.7% annual growth) Path proposals (5.5% annual growth) 5.2 $5 Constant (2009) proportion of GDP (4.7% annual growth) 4.6 $4 4.2 $3 2.6 $2 Cumulative reduction in NHE through 2020: $3 trillion $1 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020Note: GDP = Gross Domestic Product. THEData: Estimates by The Lewin Group for The Commonwealth Fund. COMMONWEALTH FUNDSource: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way,February 2009.
    • 25 Trend in the Number of Uninsured, 2009–2020 Under Current Law and Path Proposal Millions 80 Current law Path proposal 59.2 60.2 61.1 57.2 58.3 60 54.7 56.0 51.8 53.3 48.9 50.3 48.0 40 19.7 20 6.3 4.1 4.1 4.1 4.1 4.2 4.2 4.2 4.2 4.0 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020Note: Assumes insurance exchange opens in 2010 and take up by uninsured occurs over two years.Remaining uninsured are mainly non-tax-filers. THE COMMONWEALTHData: Estimates by The Lewin Group for The Commonwealth Fund. FUNDSource: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way,February 2009.
    • 26 Major Sources of Savings Compared with Projected Spending, Net Cumulative Reduction of National Health Expenditures, 2010–2020 Affordable Coverage for All: Ensuring Access and Providing a 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 Infrastructure and 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 THEData: Estimates by The Lewin Group for The Commonwealth Fund. COMMONWEALTH FUNDSource: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way,February 2009.
    • 27 Estimated Premiums for New Public Plan Compared with Average Individual/Small Employer Private Market, 2010 Average annual premium for equivalent benefits at community rate* $15,000 Public plan Private plans outside exchange, small firms Public plan premiums 20%–30% lower than traditional fee-for-service insurance $10,800 $10,000 $8,988 $5,000 $4,164 $2,904 $0 Single Family* Benefits used for modeling include full scope of acute care medical benefits; $250 individual/$500 familydeductible; 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. THE COMMONWEALTHData: Estimates by The Lewin Group for The Commonwealth Fund. FUNDSource: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way,February 2009.
    • 28 Path Net Cumulative Impact on National Health Expenditures (NHE) 2010–2020 Compared with Baseline, by Major Payer GroupsDollars in billions Net Net Private Total NHE federal state/local Households employers government government 2010–2015 –$677 $448 –$344 $111 –$891 2010–2020 –$2,998 $593 –$1,034 –$231 –$2,325Note: A negative number indicates spending decreases compared with projected expenditures (i.e., savings);a positive indicates spending increases. THE COMMONWEALTHData: Estimates by The Lewin Group for The Commonwealth Fund. FUNDSource: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way,February 2009.
    • 29 Savings Can Offset Federal Costs of Insurance: Federal Spending Under Two Scenarios Dollars in billions Net federal spending with insurance alone $350 Federal spending with insurance plus payment and system $300 $250 $250 $200 $169 $150 $99 $100 $70 $62 $50 $4 $0 2010 2015 2020 THEData: Estimates by The Lewin Group for The Commonwealth Fund. COMMONWEALTH FUNDSource: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way,February 2009.
    • 30 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 THE – Information on comparative effectiveness and evidence-based COMMONWEALTH FUND medicine
    • 31 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 THE COMMONWEALTH FUND