An overview and analysis of the Commonwealth Fund's annual report and how health IT could bring about different results.

1. National Juxtapositions
in Healthcare Delivery & Quality:
An Overview & Analysis of the
Commonwealth Fund Annual Report
Eric Luellen
American Healthcare System
May 2016

2. Who & What is the Commonwealth Fund?
• “A private foundation that aims to
promote a high performing health
care system.” Advocates for US
healthcare system reform.
• Founded in 1918 by spouse of the
Harkness Family, a Rockefeller family
and Standard Oil Company financier.
• Endowment of $99 million from
1919 to 1959 ($852M today).
• Since 2013, lead by Democratic
political activist David Blumenthal
(former chief healthcare policy
advisor to Dukakis and Obama); and,
COO/CFO/Treasurer/Secretary is a
Hillary Clinton political appointee.
(Commonwealth Fund, 2016)

3. Annual Reports
• Compares the US health care system across 80 metrics in five
categories with 10 of the world’s 195 sovereign nations.
• Began in 2000; however, most known for reports from 2011-2015
• This analysis is based on their 2014 report: “Mirror, Mirror on the
Wall: How the Performance of the U.S. Health Care System Compares
Internationally.”
• Primary “Finding:” The US has the worse health care system in the
world because it lacks universal government health care.
(Commonwealth Fund, 2016)

4. Ratings & Conclusions
(Commonwealth Fund, 2016)

5. Ratings & Conclusions
The United States spends
the most per citizen on
health care
The United States spends
the most on health care as
a percentage of gross
domestic product
(Commonwealth Fund, 2016)

6. Ratings & Conclusions
The United States
healthcare delivery and
quality has allegedly fallen
from 5th in the world to
11th in the world amongst
11 industrialized nations
The decline is accelerating
(increasing at an increasing
rate) by falling four places
in one year (2013-2014).
(Commonwealth Fund, 2016)

7. The “Worst” Categories & Overall
Definitions
1. Timeliness of Care – A seven-question composite related to whether patients could see a
provider same-day without an appointment, on holidays, emergency waits over two hours,
whether doctors perceive patients have to wait for tests and treatment, specialist waits over
two months, and elective procedure waits over four months. (Karen Davis, 2014)
2. Efficiency – Healthcare efficiency, for the purposes of this report, is defined by analogy thusly:
“an efficient, high-value health care system seeks to maximize the quality of care and
outcomes given the resources committed, while ensuring that additional investments yield net
value over time.” (Karen Davis, 2014)
3. Equity – The World Health Organization defines healthcare equity as “the absence of avoidable
or remediable differences among groups of people, whether those groups are defined socially,
economically, demographically, or geographically.” The WHO is careful to specify that this
includes the degree to which these inequalities are being corrected. (WHO, 2016)
4. Healthy Living – A three-question composite related to “mortality amenable to medical care,”
infant mortality, and predicted life-expectancy at age 60 years. (Karen Davis, 2014)
(Commonwealth Fund, 2016)

8. Improving Timeliness of Care with Health IT
(Kahn, 2015)
Challenges
• Quality control & effectiveness fears
• Regulating quality inter-jurisdictionally
because of Internet and globalization
• Palpitations and contact unavailable.
Telehealth Consultations
• Expands access while overcoming
geographic, economic, and
sociological barriers
• Potential to improve health care by
increasing access to more
knowledgeable specialists
• Has potential to lower health care
costs by reducing travel and overhead.
• Improves timeliness by finding
providers when available, no wait.

9. Improving Efficiency with Health IT
(William B. Weeks, 2016)
Patient Engagement Platforms
• Complex event processing (CEP) can
proactively monitor & alert behaviors
• Prevents medication non-adherence and
drug-drug interactions
• Coordinates care across disparate team of
health care providers
• Improves patients’ perceptions of care
• Provides big data for knowledge discovery
and evolving health care
• Promotes shared decision making
• Prevents adverse events to reduce cost
and improve value and efficiency – pay
for patient performance
Challenges
• Quality control & effectiveness fears
• Regulating quality inter-jurisdictionally
because of Internet and globalization
• Palpitations and contact unavailable.

10. Improving Equity with Health IT
(Halamka, 2015)
Clinical Decision Support Systems
• Patients anywhere can have
superlative diagnoses quality,
even better than human.
• Reduces gaps or delays between
diagnoses and treatment.
• May be the future of much of
medical diagnoses because of
sequencing and functioning of
genome, biome, and
proteinomics.
Challenges
• Asking the right questions key; limited
patient knowledge is challenging.
• Natural language (NLP) is also
problematic, few standardized terms.
• Adoption by providers challenging
because it evolves their role & power.

11. Commonwealth Fund Reports: Fact or Fiction
Methodological and statistical analysis
reveals that the report is more
appropriately classified as political
propaganda than science;
It relies on statistics that are knowingly
inaccurate to advocate a political
outcome, which is also an inaccurate
conclusion;
In other words, it draws non-factual
conclusions from knowingly inaccurate
data that, even if the data were
accurate, would reasonably lead to
different conclusions.
For example:
• Each country uses different accounting
methods, which the authors fail to reconcile;
• Globally, health care costs are commonly
under reported because provider
incomes are excluded;
• European reimbursement rates in at least
nine countries are known to be off by as
much as 50%;
• One key metric, survival rates, is excluded
from their analysis;
• The conclusion cannot be that countries with
universal health care rank higher because
each of those countries has a different system
of care.
(John Goodman, 2009)

12. Lessons Learned – The Pros & The Cons
The Cons
• The Commonwealth Fund is more of a
political advocacy group than an
objective and independent scientific
authority.
• Its reports distort facts, report facts it
knows or should know are false, and
claim unrelated conclusions to
support their political agenda.
• Different accounting systems make it
difficult to compare national health
systems; however, the WHO has
ranked the US health care system at
37 out of 195, not the lowest.
The Pros
• The US, and many nations, have
significant room for improvement in
the timeliness, efficiency, and equity
of health care delivery.
• Health information technology (HIT)
such as telehealth, patient
engagement systems, and clinical
diagnostic decision support systems
have a probability of significantly
improving these areas.

13. Works Cited
Commonwealth Fund. (2016, May 21). About Us: Foundation History. Retrieved from The Commonwealth Fund: http://www.commonwealthfund.org/about-
us/foundation-history
Halamka, J. D. (2015, December 23). Using Big Data to Make Wiser Medical Decisions. New England Journal of Medicine, pp. http://catalyst.nejm.org/using-
big-data-to-make-wiser-medical-decisions/
John Goodman, L. G. (2009, March 10). Health Care Reform: Do Other Countries Have the Answers? . Retrieved from National Center for Policy Analysis:
http://www.ncpa.org/pdfs/sp_Do_Other_Countries_Have_the_Answers.pdf
Kahn, J. M. (2015). Virtual Visits — Confronting the Challenges of Telemedicine. New England Journal of Medicine, 1684-1685.
Karen Davis, K. S. (2014, June). Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. Retrieved from
The Commonwealth Fund: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf
WHO. (2016, May 21). Health Systems: Equity. Retrieved from World Health Organization: http://www.who.int/healthsystems/topics/equity/en/
WHO. (2016, May 21). World Health Organization’s Ranking of the World’s Health Systems. Retrieved from The Patient Factor:
http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/
William B. Weeks, J. N. (2016, March 9). Patient-Reported Data Can Help People Make Better Health Care Choices. New England Journal of Medicine
Catalyst, pp. http://catalyst.nejm.org/patient-reported-data-can-help-people-make-better-health-care-choices/
Disclosures
The author is the co-founder of iDok, and currently serves as the Chief Executive Officer of Bioinformatix, LLC, the
developer of Rx&You.