This presentation by Cathy Schoen, Senior Vice President of the Commonwealth Fund, uses results from the Fund’s annual International Health Policy surveys plus US examples to illustrate the potential to re-design health care in the 21st century with a focus on primary care linked to a continuum of care. Cathy shares insights gleaned from the Commonwealth Fund’s three most recent international surveys—general population (2013), primary care doctors (2012), and adults with complex medical conditions (2011)—that compare Australia with 10 other countries. Cathy also highlights examples of care system innovation and improvement.

1. Re-Engineering Care for 21st Century
High Performance Health Systems
Potential to Improve and Opportunities to Learn
Insights from Cross-National Experiences
Sydney, June 19, 2014
Cathy Schoen, Senior Vice President
The Commonwealth Fund
www.commonwealthfund.org

2. Improving Primary Care and Care Systems for
21st Century Health Systems
• Patient-Centered, High Performance Care Systems
– Goals: Accessible, High Quality (Outcomes/Health)
and Sustainable Costs
– Potential of primary care, teamwork and care
continuum
• Insights International Surveys
– Insurance design matters for access, affordability
and complexity
– “Medical homes” make a positive difference
• Innovative models – U.S. examples
– Information and new communication technology
• Opportunities to learn from country initiatives
2

3. Patient-Centered Care and Care Systems: Primary
Care Foundation Connected to Care System
3

4. Recent International Surveys
in Eleven Countries
• 2013: General population
– Access, cost, insurance complexity, country views
• 2012: Primary care doctors
• 2011: “Sicker” adults (recent hospital stay, surgery,
illness, fair/poor health)
– Coordination, communication, chronic disease
• Eleven Countries:
– Australia, Canada, France, Germany, Netherlands,
New Zealand, Norway, Sweden, Switzerland, U.K.,
and United States
• Australia BHI partner/co-fund expanded NSW survey
4

5. Insights from Patients’ and Doctors’
Experiences
• Access and affordability
–Insurance design matters
• Coordination a shared concern
• Enhanced primary care makes a positive
difference
• Country differences often linked to
underlying policies
5

6. 66
Overall Views of Health Care System, 2013
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries
25
40
42
42
44
46
47
48
51
54
63
48
49
50
48
46
42
45
43
44
40
33
27
11
8
10
10
12
8
9
5
7
4
0% 25% 50% 75% 100%
US
FR
CAN
GER
SWE
NOR
NZ
AUS
NETH
SWIZ
UK
Works well, only minor change Fundamental change Completely rebuild
Percent

7. 77
4
6
10
13 13
15 16
18
21 22
37
27
0
10
20
30
40
50
Experienced a Cost-Related Access Problem
in the Past Year, 2013
Percent*
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
* Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.
US
Insured

8. 88
Out-of-Pocket Costs and Problems Paying Medical Bills
in the Past Year, 2013
Percent
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries
2 3
7 7
9
11
14
17
24 25
41
0
10
20
30
40
50
Spent US$1,000 or more
out-of-pocket
Had Serious Problems Paying
or Unable to Pay Medical Bills
1
4
6 7 7 8 9 10 10
13
23

9. 99
76
72
63
58 58 57
52 52
48
41
0
25
50
75
100
Access to Doctor or Nurse When Sick
or Needed Care, 2013
Percent
5
14 14 15 16 16
22
26 28
33
Same-day or next-day
appointment
Waited six days or more
for appointment
Note: Question asked differently in Switzerland.
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries

10. 10
69
56 56 54
49 46
39 38 36 35
0
20
40
60
80
100
Access to After-Hours Care
Percent
95 95
90 90
81 78 76
68
46
35
Adults, 2013
Easy getting after-hours care
without going to the ER
Primary care physicians, 2012
Practice has arrangement for
patients’ after-hours care
to see doctor or nurse
Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys
Base: Needed care after hours.

11. 11
22 22 24
27 28 28 28
31 32
39 41
48
0
5
0
5
AUS GER NETH UK NZ NOR SWIZ FR SWE US CAN
Used Emergency Department
Past Two Years, 2013
Percent
US
Uninsured
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries

12. 1212
80 80
76 75 72
59
54 51 51
46
39
0
25
50
75
100
Wait Times for Specialist Appointment
Percent
3 3 6 7 10
17 18 18 19
26 29
Less than four weeks Two months or more
Base: Needed to see specialist in the past two years.
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

13. Patients: Report problems with
insurance complexity*
Insurance Complexity & Restrictions Concerns
for Patients and Doctors
4 4
7 8
15 16 17 19
23 25
32
0
30
60
Percent
10 11 12 12
18 20
23 24
28
41
54
Primary care doctors:
Insurance care restrictions pose
major time concern**
Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys
* Adults spent a lot of time on paperwork or disputes over medical bills and/or insurance denied payment
or did not pay as much as expected in the past year.
** Amount of time doctor or staff spend getting patients needed medications/treatments because of coverage
restrictions is a major problem.
13

14. Engaging Patients and Care Coordination
14

15. Patient Engagement in Care Management
for Chronic Condition, 2011
Percent reported
professional in past
year has:
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Discussed your
main goals/
priorities
63 67 42 59 67 62 51 36 81 78 76
Helped make
treatment plan
you could carry
out in daily life
61 63 53 49 52 58 41 40 74 80 71
Given clear
instructions on
symptoms and
when to seek
care
66 66 56 64 64 63 44 49 84 80 75
Yes to all three 48 49 30 41 42 45 23 22 67 69 58
15
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries
Base: Has chronic condition.

16. 16
Sicker Adults: Coordination Gaps, 2011
20 23
30
36 37 39 40 42 43
53 56
0
20
40
60
80
UK SWIZ NZ AUS NETH SWE CAN US NOR FR GER
Percent had any gap in past 2 years*
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to
share important information with each other, specialist did not have information about medical history, and/or regular doctor not
informed about specialist care.

17. 17
26 29
48 50 51 55
61
66 67 71 73
0
20
40
60
80
100
UK US SWIZ CAN NZ AUS GER NETH SWE NOR FR
Percent any gap in past two years*
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries
* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know
who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements
made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.
Gaps in Hospital or Surgery Discharge
Planning, 2011

18. Transforming Primary Care
Patient-centered teams and Care Systems
• Patients receive enhanced
access to primary care,
well coordinated by a team
• Patients actively engaged
(treatment decisions, care
at home)
• Teams use decision-
support tools, assess
performance with payment
support
• Linked to care continuum –
care system; health focus
2020 Vision
Accessible
Patient Centered
Coordinated Care
18

19. Patients with a Regular Doctor vs. Medical Home, 2011
19
99 99 99
91
99 99 97 96 97 100
95
74 70
65
56 53 52 51 49 48 48
33
0
20
40
60
80
100
UK SWIZ NZ US NOR FR AUS CAN GER NETH SWE
Has a regular doctor or place of care
Has a medical home
Percent
Patients with a medical home have a regular practice who is accessible, knows
them, and helps coordinate their care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries

20. 20
79
70
59
72
65
76
36
55
82 79 80
52
38 40
50
40
45
18
28
51 54
41
0
20
40
60
80
100
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Medical home No medical home
Percent reporting positive patient-doctor
relationship and communication*
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries
Patient-Doctor Communication, by Medical Home, 2011
Base: Has a regular doctor/place of care.
* Regular doctor always/often: spends enough time with you, encourages you to ask questions, and explains things in a way
that is easy to understand.

21. Patient Engagement in Care Management
for Chronic Condition, by Medical Home, 2011
21
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Base: Has chronic condition.
Percent reporting positive patient engagement
in managing chronic condition*
* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make
treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.
56 59
34
47
54 51
29 32
73 76
67
38 38
24
33
29 27
16 15
51
46 45
0
20
40
60
80
100
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Medical home No medical home

22. 31 30
49
53
32
25
36
32
20
15
33
41
49
57 59
42 41
51
42
30 33
54
0
20
40
60
80
100
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Medical home No medical home
22
Experienced Coordination Gaps in Past Two Years,
by Medical Home, 2011
Percent*
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to
share important information with each other, specialist did not have information about medical history, and/or regular doctor not
informed about specialist care.

23. 23
Hospital or Surgery Discharge Planning Gap
by Medical Home, 2011
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries
* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know
who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements
made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.
49
43
66
60 59
42
64
59
41
17 19
63
57
82
63
74
68
78
70 67
53
46
0
20
40
60
80
100
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Medical home No medical home
Percent*

24. 24
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries
Medical, Medication, or Lab Test Errors in Past Two Years,
by Medical Home, 2011
* Reported medical mistake, medication error, and/or lab test error or delay in past two years.
15 15
10
15 16
19
22
16
6 6
17
23
27
15
18
23
29 29
22
15 14
29
0
10
20
30
40
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Medical home No medical home
Percent*

25. Patient-Centered, Coordinated Primary Care
Medical Homes as Part of Systems Approach
• Systems approach: Access, Quality, Efficiency
• Primary care/care systems across care continuum
– Timely access to care: multiple points of access
– Patient engagement in care
– Information systems: quality & coordination
– Routine feedback of patient and clinical outcomes
– Coordinated care, creative use of teams
– Incentives and system support to improve/innovate
Approach to redesigning primary care - systems
– Part of “system” of care the aims to organize care
around patients and focus on outcomes
25

26. Community Care of North Carolina
Multiple Models of Care Systems and Teamwork
26

27. 27
Enhanced Primary Care/Care Systems:
Cost and Quality Outcomes
Geisinger Health System (Pennsylvania)
• 18% reduction in all-cause hospital admissions; 36% lower readmissions
• 7% total medical cost savings
Mass General High-Cost Medicare Chronic Care Demo (Massachusetts)
• 20% lower hospital admissions; 25% lower ED use; 7% net savings annual
• Mortality-decline: 16% compared to 20% in control group
Guided Care - Geriatric Patients (Baltimore, Maryland-Washington, DC, area)
Among patients in an integrated care delivery system:
• 47% reduction in skilled-nursing facility admissions
• 52% reduction in skilled-nursing facility days
Group Health Cooperative of Puget Sound (Seattle, Washington)
• 29% reduction in ER visits; 11% reduction ambulatory sensitive admissions
Health Partners (Minnesota)
• 29% decrease ED visits; 24% decrease hospital admissions
Intermountain Healthcare (Utah)
• Lower mortality; 10% relative reduction in hospitalization
• Highest $ savings for high-risk patients

28. Division of Population Health Management
Evidence based care improvement tactics
Milford, CE, Ferris TG (2012 Aug). A modified “golden rule” for health care organizations. Mayo Clin Proc. 87(8):717-720.
Longitudinal Care Episodic Care
Primary Care Specialty Care Hospital Care
Access to care
Patient portal/physician portal Access program
Extended hours/same day appointments Reduced low acuity
admissions
Expand virtual visit options
Design of care
Defined process standards in priority conditions (multidisciplinary teams)
High risk care
management
Shared decision
making
Re-admissions
Hospital Acquired
Conditions
100% preventive
services
Appropriateness Hand-off and
continuity programs
Chronic condition management
EHR with decision support and order entry
Measurement
Variance reporting/performance dashboards
Quality metrics: clinical outcomes, satisfaction
Incentive programs
Costs/population Costs/episode

29. Pennsylvania: Geisinger Medical “Navigator” Home Sites and
Hospital Admissions/Readmissions
300
325
350
375
400
425
450
CY 2006 CY 2007
Medical Home Non-Medical Home
Source: Geisinger Health System, 2009. *Results reported in: R. Gilfillan et al, “Value and the Medical Home: Effects
of Transformed Primary Care,” The American Journal of Managed Care, 16(8) 2010: 607-614.
Hospital admissions per 1,000 Medicare patients
• 18% reduction in hospital admissions
• 36% reduction in hospital readmissions
• 7% total medical cost savings
19.5
15.9
0
5
10
15
20
25
CY 2006 CY 2007
Readmission Rates for All
Medical Home Sites
As of Q4-2008*:

30. 30
Health IT Framework
Evaluation Framework
Medical
Home
Hospital
s
Public Health
Programs & Services
Community Health Team
Nurse Coordinator
Social Workers
Nutrition Specialists
Community Health
Workers
MCAID Care
Coordinators
Public Health Specialist
Specialty Care & Disease
Management Programs
 A foundation of medical homes and
community health teams that can
support coordinated care and
linkages with a broad range of
services
 Multi Insurer Payment Reform that
supports a foundation of medical
homes and community health teams
 A health information infrastructure
that includes EMRs, hospital data
sources, a health information
exchange network, and a
centralized registry
 An evaluation infrastructure that
uses routinely collected data to
support services, guide quality
improvement, and determine
program impact
Mental Health &
Substance Abuse
Programs
Medical
Home
Medical
Home
Medical
Home
Social, Economic, &
Community
Services
Healthier Living
Workshops
Vermont: Shared Resources Community Teams

31. INTERACT Collaborative Quality
Improvement for Nursing Homes
 Three strategies:
• Identify, assess, and manage conditions to prevent
hospitalization
• Document and communicate critical information
• Improve advance care planning and develop palliative care
plans
Source: J. G. Ouslander, G. Lamb, R. Tappen et al., "Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation
of the INTERACT II Collaborative Quality Improvement Project," Journal of the American Geriatrics Society, April 2011.
Interventions to Reduce
Acute Care Transfers
(INTERACT) helps nursing-
home staff manage
residents’ health status
 17-25% decline in hospital
admissions in pilot
 Spreading to 400+ homes
31

32. 32
Creative Use of Information
and Communication Technology

33. 33
Robert Kahn
Cincinnati Children’s Hospital System Presentation to Commonwealth Fund Board of Directors , April 2012
County neighborhoods
Variation in Asthma Admission Rates
within a Single County, Cincinnati,OH
33

34. 34
• Interdisciplinary teams; home and community care; transition care
• Care and assist with navigating complex health care systems
• Patient-centered: targets and customizes interventions
• Strong health information technology and EHR; Support team
• Positive results
• Improved primary care access; high quality and patient ratings
• Reduce hospital admissions, readmissions, ER use (17 to 27%)
• Links primary, specialist and long term care
• Patient and family preferences
Visiting Nurse Service New York Health Plans
Patient-Centered Care Teams for High-Cost Chronically Ill Medicare
and Medicaid – Special Needs and Long Term Care
Summary of presentation by Carol Raphael, Pres and CEO, NY Visiting Nurse Assn., 6/2011

35. Telehealth & Electronic Communication
• Veteran’s Health Administration
• North Dakota Telepharmacy (rural)
• E-consults and referrals
―Mayo Clinic: Minnesota
―San Francisco General
―Group Health: Seattle
35
• Kaiser Permanente integrated system:
web-access, e-visits, “real” time data
• U. Tennessee Memphis: specialist
remote consultation (3 state region)

36. 8.77
14.27
17.94
26.93
51.65
45.68
26.0
19.98
16.08
12.22
0
10
20
30
40
50
60
70
Very Low Low Intermediate High Very High
Predicted Readmission Risk Category
Derivation Samples
Validation Samples
Parkland, Texas: An EMR model to predict 30-day readmission for heart failure
using SES risk and clinical risk. Model includes: systolic and diastolic blood pressure, pulse, temperature,
pH, BNP, PT/ INR, glucose, CK-MB, troponin, wbc, pCO2, BUN, sodium, creatinine, CK, bilirubin, albumin, age, history of
depression, single, male, no. of home address changes, medicare, high risk census tract, cocaine use, missed clinic visit,
used pharmacy, prior inpatient admissions, ED presentation time. C-statistic: Derivation: 0.73; Validation 0.69
Source: Ruben Amarasingham, MD, Parkland Health and Hospital System, Presentation to Commonwealth
Fund on May 12, 2010, “Harnessing Electronic Medical Record Data to Reduce Readmissions.”
Hospital: Use of IT to Predict Risk and Marshal
Resources, Including Transition Care/Discharge
36

37. Health Care and Population Health:
Digital Age Enables Dynamic System Redesign
• Whole system view
– Gains in health and value if we use resources
creatively and productively
– Teams (including virtual teams) with information
– Beyond “facilities”: care continuum
• Strategic focus on key areas
– Transforming primary care linked to care systems
– Creative use of electronic health information and
digital technology
– Shared resources
• Supportive Policies: Align Payment, Insurance
Design and Regulations with Value
37

38. 38
Payment Reform: Value
Keys to Better Care, Better Health, and Lower Costs
Information
Systems
Teams and Care
System Redesign

39. 39
For More Information, Including Survey Data
Visit www.commonwealthfund.org