Fixing the u s health system state by state
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Fixing The U.S. Health System State By State. Stephen C. Schoenbaum, MD, MPH Executive Vice President for Programs April 26, 2007 www.cmwf.org Kentucky Institute of Medicine. Commonwealth Fund’s Commission on a High Performance Health System. Objective:

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Fixing the u s health system state by state

Fixing The U.S. Health System State By State

Stephen C. Schoenbaum, MD, MPH

Executive Vice President for Programs

April 26, 2007

www.cmwf.org

Kentucky Institute of Medicine


Commonwealth fund s commission on a high performance health system

Commonwealth Fund’s Commission on a High Performance Health System

Objective:

  • The overarching mission of a high performance health care system is to help everyone, to the extent possible, lead long, healthy, and productive lives

  • To the Commission, a high performance health system is designed to achieve four core goals

    • high quality, safe care

    • access to care for all people

    • efficient, high value

    • system capacity to improve


Us scorecard us falls short of benchmarks on all dimensions of a high performance health system

US Scorecard: US Falls Short of Benchmarks on All Dimensions of a High Performance Health System

SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006


State health system performance summary

Top Quarter

2nd Quarter

3rd Quarter

Bottom Quarter

State Health System Performance Summary


Lessons from the scorecard

Lessons From The Scorecard

  • Care far from “perfect”

  • Tremendous variation within the US

  • Possible to have higher quality and lower cost

  • We need to address multiple issues simultaneously – e.g., coverage, efficiency, quality


The discourse is changing

The Discourse Is Changing

FROM:

  • “Americans have the best health care system in the world”

    • President Bush, State of the Union Speech, 2004

      TO:

  • We need to do better

    • We spend more on health care than any other country

    • We need more value for what we are spending


  • We know the problems now we need solutions

    We Know The ProblemsNow We Need Solutions


    Keys to transforming the u s health care system

    Keys to Transforming the U.S. Health Care System

    • Extend health insurance coverage to all

    • Pursue excellence in provision of safe, effective, and efficient care

    • Organize the care system to ensure coordinated and accessible care for all

    • Increase transparency and reward quality and efficiency

    • Expand the use of information technology and information exchange

    • Develop the workforce to foster patient-centered and primary care

    • Encourage leadership and collaboration among public and private stakeholders


    Fixing the u s health system state by state

    1. Extend Health Insurance Coverage to All


    Uninsured non elderly adult rate rapidly deteriorating

    ACCESS: UNIVERSAL PARTICIPATION

    1999–2000

    2004–2005

    NH

    NH

    ME

    WA

    NH

    VT

    ME

    WA

    VT

    ND

    MT

    ND

    MT

    MN

    MN

    OR

    NY

    MA

    WI

    OR

    MA

    NY

    ID

    SD

    WI

    RI

    MI

    ID

    SD

    RI

    WY

    MI

    CT

    PA

    WY

    NJ

    CT

    IA

    PA

    NJ

    NE

    IA

    OH

    DE

    IN

    NE

    OH

    NV

    DE

    IN

    IL

    MD

    NV

    WV

    UT

    VA

    IL

    MD

    CO

    DC

    WV

    UT

    VA

    KS

    MO

    KY

    CA

    CO

    DC

    KS

    MO

    KY

    CA

    NC

    NC

    TN

    TN

    OK

    SC

    AR

    OK

    AZ

    NM

    SC

    AR

    AZ

    NM

    MS

    GA

    AL

    MS

    GA

    AL

    TX

    LA

    TX

    LA

    FL

    FL

    AK

    AK

    23% or more

    HI

    HI

    19%–22.9%

    14%–18.9%

    Less than 14%

    Uninsured Non-Elderly Adult Rate Rapidly Deteriorating

    Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute.

    Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006


    Percent of uninsured children declined since implementation of schip

    ACCESS: UNIVERSAL PARTICIPATION

    1999–2000

    2004–2005

    NH

    ME

    WA

    NH

    VT

    ME

    WA

    VT

    ND

    MT

    ND

    MT

    MN

    MN

    OR

    NY

    MA

    WI

    OR

    MA

    NY

    ID

    SD

    WI

    RI

    MI

    ID

    SD

    RI

    WY

    MI

    CT

    PA

    WY

    NJ

    CT

    IA

    PA

    NJ

    NE

    IA

    OH

    DE

    IN

    NE

    OH

    NV

    DE

    IN

    IL

    MD

    NV

    WV

    UT

    VA

    IL

    MD

    CO

    DC

    WV

    UT

    VA

    KS

    MO

    KY

    CA

    CO

    DC

    KS

    MO

    KY

    CA

    NC

    NC

    TN

    TN

    OK

    SC

    AR

    OK

    AZ

    NM

    SC

    AR

    AZ

    NM

    MS

    GA

    AL

    MS

    GA

    AL

    TX

    LA

    TX

    LA

    FL

    FL

    AK

    AK

    16% or more

    HI

    HI

    10%–15.9%

    7%–9.9%

    Less than 7%

    Percent of Uninsured Children Declined Since Implementation of SCHIP

    Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute.

    Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006


    State action on employer coverage

    State Action on Employer Coverage

    In 2006, nearly 30 states considered bills to require employers to offer health insurance or pay in some way to cover the uninsured. So far in 2007, similar plans have been proposed in 14 states.

    2006 legislation passed

    2007 proposals introduced

    2006 legislation failed but 2007 proposals introduced

    Sources: National Conference on State Legislatures and American Legislative Exchange Council

    2006 legislation failed


    Massachusetts health care reform

    Massachusetts Health Care Reform

    • Enacted 4/06

    • MassHealth expansion for children up to 300% FPL; adults up to 100% poverty

    • Individual mandate, with affordability provision; subsidies between 100% and 300% of poverty

    • Employer mandatory offer, employee mandatory take-up

    • Employer assessment ($295 if employer doesn’t provide health insurance)

    • “Connector” to organize affordable insurance offerings through a group pool

    Source: John Holahan, “The Basics of Massachusetts Health Reform,” Presentation to United Hospital Fund, April 2006.


    Update massachusetts health care reform

    Update: Massachusetts Health Care Reform

    • The Commonwealth Connector Authority approved draft regulations on creditable coverage:

      • Prescription drugs

      • Coverage of preventive services prior to deductible

      • Caps on annual deductible and out of pocket costs for hospital and physician services

      • No limits on benefits per year per sickness

    • New plans called Commonwealth Choice go on sale May 1 and go into effect July 1, 2007

    • Deductibles range from $0 to $2,000

    • Phased-in “minimum coverage” requirement, fully in effect January 1, 2009

    • Connector Authority currently developing criteria for exempting individuals from requirement


    Massachusetts strategies for coverage everyone does their part

    Massachusetts Strategies for Coverage: Everyone “does their part”

    Government

    Health Care

    System

    • Subsidized insurance

    • The Connector

    • Uncompensated Care pool reform

    • Improved Medicaid reimbursement

    • Meet quality and performance standards

    • New levels of “transparency”

    Expanded

    Coverage

    Employers

    Individuals

    • Fair Share Assessment

    • “Free Rider” provisions

    • Mandatory “cafeteria plans”

    • Individual Mandate

    Source: Adapted from Amy Lischko, October 16, 2006. “Massachusetts Health Reform.” NASHP 19th Annual State Health Policy Conference, Pittsburgh, PA.


    Targeted state coverage innovations

    Targeted State Coverage Innovations


    Small business programs

    Small Business Programs

    • Montana: Insure Montana (2-9- employees)

      • Refundable tax credits ($100-125/employee/month)

      • Small business purchasing pool (subsidized from increased tobacco tax)

      • 8000 enrollees in first year

    • New Mexico: State Coverage Insurance (<50 employees)

      • Waiver to expand Medicaid eligibility to uninsured working adults <200% FPL

      • 4400 enrollees, Fall 2006


    States targeting employees of small businesses

    States Targeting Employees of Small Businesses

    • Oklahoma: Insure Oklahoma (<50 employees):

      • Premium assistance pays 60% of premium for low income workers; employer pays 25%; employee pays up to 15%.

      • Funded from tobacco tax, federal Medicaid match, and employer/employee contributions

      • 1200 enrollees

    • New York: Healthy New York (small employers with 30% or more employees earning < $34,000)

      • State reinsurance keeps premiums affordable

      • 125,000 enrollees, Fall 2006


    Covertn

    CoverTN

    • Limited-benefit “minimedical” plan launched by Governor Phil Bredesen in March 2007 to offer low-cost insurance to small businesses and uninsured working Tennesseans

    • Administered by BlueCross Blue Shield; Premiums shared by employer, employee, and the state. Each pay between $34 - $99/month.

    • Option of two plans, both with no deductible and modest co-pays ($15-$20 for doctor visits; $100 for hospital stays).

      • Plan A: Covers hospital stays up to $15,000 per year and up to $75 every three months for drugs

      • Plan B: Covers hospital stays up to $10,000 per year and up to $250 every three months for drugs

    • Currently enrolled: 1,053 individuals; 89 hospitals; 10,000 physicians; 12,000 businesses pre-qualified


    New jersey raises age of dependent status for health insurance

    New Jersey Raises Age of Dependent Status for Health Insurance

    Millions uninsured, adults ages 19–29

    • As of 5/2006, NJ requires all state insurers to raise dependent age limit to 30

      • Highest age limit in country

      • Covers uninsured, unmarried adults with no dependents who are either NJ residents or full-time students

      • Premium capped at 102% of amount paid for dependent’s coverage prior to aging out

    • 200,000 young adults expected to receive coverage under the law

    Source: S.R. Collins, C. Schoen, J.L. Kriss, M.M. Doty, B. Mahato, “Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help,” Commonwealth Fund issue brief, May 2006. (Analysis of the March 2001–2005 Current Population Surveys)


    Illinois all kids

    Illinois All-Kids

    • Effective July 1, 2006

    • Available to any child uninsured for 12 months or more

    • Cost to family determined on a sliding scale

    • Linked to other public programs - FamilyCare & KidCare

    • Funded by federal and state funds

      • Children <200% of the federal poverty level funded by federal funds

      • Children 200%+ of the federal poverty level funded by state savings from the Medicaid Primary Care Case Management Program

    • All-Kids Training Tour

      • Public outreach program to highlight new and expanded healthcare programs

    • Enrollment as of Fall 2006 was 28,600


    New bold state proposals

    New Bold State Proposals


    California governor s proposal 1 07

    California Governor’s Proposal (1/07)

    • Individual mandate

    • Shared responsibility

    • Medi-Cal expansion

      • All children below 300% poverty

      • Adults below 100% poverty

    • Premium subsidies for adults below 250% poverty

    • Employers must provide health insurance or pay a fee of 4% of wages

    • Provider fee assessment (2% of physician revenues to 4% of hospital revenues)

    • Insurance exchange

      • Guaranteed issue; community rating with age bands

      • 85% minimum medical loss ratio

    Source: D. Rowland, “California Health Reform Proposal,” Kaiser Commission on Medicaid and the Uninsured, Presented January 13, 2007.


    Extending coverage is only one piece of the puzzle

    Extending Coverage is Only One Piece of the Puzzle

    3. Organize the Care System to Ensure Coordinated and Accessible Care for All

    1. Extend Health Insurance Coverage to All

    2. Pursue Excellence in Provision of Safe, Effective, and Efficient Care

    7. Encourage Leadership

    and Collabor-

    ation Among

    Public

    5. Expand the Use of Information Technology and Exchange

    4. Increase Transparency and Reward Quality and Efficiency

    And Private Stakeholders

    6. Develop the Workforce to Foster Patient-Centered and Primary Care


    Delaware health information exchange

    Delaware Health Information Exchange

    • Delaware Health Information Network

      • Public-private partnership established in 1997 to assist in the creation of a statewide health information and electronic data interchange network for public and private use.

      • Functions under the direction of the Delaware Health Care Commission.

      • In 2006 signed an extendable 6-year contract with technology vendor Medicity, Inc. to create the first statewide health information exchange (Start-up costs =$4 to 5 million).

    • Interoperable Health Information Exchange

      • Gives physicians access to secure, fast, and reliable electronic patient information at the time and place of care.

      • Funded by participating health care organizations, the State of Delaware, and the Federal Agency for Healthcare Research and Quality in the U.S. Department of Health and Human Services.


    Community care of north carolina

    Community Care of North Carolina

    Asthma Initiative: Pediatric Asthma Hospitalization

    Rates (April 2000 – December 2002)

    • 15 networks, 3500 MDs, >750,000 patients

    • Receive $2.50 PM/PM from the State

    • Hire care managers/medical management staff

    • PCP also get $2.50 PMPM to serve as medical home and to participate in disease management

    • Care improvement: asthma, diabetes, screening/referral of young children for developmental problems, and more!

    • Case management: identify and facilitate management of costly patients

    • Cost (FY2003) - $8.1 Million; Savings (per Mercer analysis) $60M compared to FY2002

    In patient admission rate per 1000

    member months

    Source: L. Allen Dobson, MD, presentation to ERISA Industry Committee, Washington, DC, March 12, 2007


    Building quality into rite care higher quality and improved cost trends

    Building Quality Into RIte CareHigher Quality and Improved Cost Trends

    Cumulative Health Insurance Cost Trend Comparison

    Percent

    • Quality targets and $ incentives

    • Improved access, medical home

      • One third reduction in hospital and ER

      • Tripled primary care doctors

      • Doubled clinic visits

    • Significant improvements in prenatal care, birth spacing, lead paint, infant mortality, preventive care

    Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003.Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005; updated.


    Prescription for pennsylvania 1 07

    Prescription for Pennsylvania (1/07)

    • Affordable basic health insurance for all

    • Promote non-emergency settings for non-emergency care

    • Improve quality by eliminating hospital-acquired infections, medical errors

    • Pay-for-performance

    • Long-term care: promote home/community services

    • Enhance pain-management, palliative care, and hospice care

    • Promote wellness and sound nutrition in the schools and by making workplaces, restaurants, and bars smoke-free


    Components of comprehensive health care reform plans

    Components of Comprehensive Health Care Reform Plans


    Ways states can promote a high performance health system

    Ways States Can Promote a High Performance Health System

    • Extend coverage – ideally to all

    • Reduce cost shifting by adequate funding of public programs

    • Simplify and streamline public program eligibility and re-determination

    • Promote safer care

      • Reporting, analysis, technical assistance

    • Promote more effective, efficient, patient-centered, timely, and coordinated care

      • Public reporting

      • Payment policies – “value-based purchasing”

    • Assure competent professionals

      • Licensure, maintenance of competence, discipline

    • Promote the use of health information technology

      • State-wide information exchanges, capital loans, technical assistance

    • Promote wellness and healthy living


    In sum

    In Sum:

    • Efforts at the state level to expand access, improve quality and efficiency are gaining momentum

    • States are learning from each other

    • States are informing the national debate


    What about kentucky

    What About Kentucky?

    DISCUSSION


    Visit the fund www cmwf org

    Visit the Fundwww.cmwf.org


    Acknowledgements

    Acknowledgements

    Karen Davis,

    President

    The Commonwealth Fund

    Cathy Schoen,

    Sr. Vice President

    Research & Evaluation

    Anne Gauthier,

    Senior Policy Director

    Commission on a High Performance Health System

    Elizabeth Sturla,

    Executive Assistant

    Rachel Nuzum,

    Program Officer

    State Innovations

    Visit the Fund at:www.cmwf.org


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