Transforming The U.S. Health System: What Needs To Be Done & Your Role

1. Transforming The U.S. Health System:What Needs To Be Done & Your Role Stephen C. Schoenbaum, MD, MPH Executive Vice President for Programs www.cmwf.org Mountainside Hospital February 8, 2007

2. What We’ll Cover • Introduction to The Commonwealth Fund and The Commission on a High Performance Health System • Goals for a high performance health system • Where we stand now • Keys to transforming the health system • What you can do

3. The Commonwealth Fund Established in 1918, The Commonwealth Fund (www.cmwf.org) is a private national foundation that aims to promote a high performing health care system by supporting independent research on health care issues and making grants to improve health care practice and policy.

4. The Commonwealth Fund Commission on a High Performance Health System Objective: • Move the U.S. toward a higher-performing health care system that achieves better access, improved quality, and greater efficiency, with particular focus on the most vulnerable due to income, gaps in insurance coverage, race and ethnicity, health, or age Chairman: James J. Mongan, M.D. President and CEO Partners HealthCare System, Inc.

5. HIGH QUALITY, SAFE, COMPASSIONATE, COORDINATED CARE ACCESS AND EQUITY FOR ALL Goals for a High Performance Health System LONG, HEALTHY, AND PRODUCTIVE LIVES EFFICIENCY CAPACITY FOR SYSTEM AND WORKFORCE INNOVATION AND IMPROVEMENT

6. Scores: Dimensions of a High Performance Health System SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

7. LONG, HEALTHY & PRODUCTIVE LIVES Mortality Amenable to Health Care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care. Deaths per 100,000 population* International Variation, 1998 State Variation, 2002 Percentiles

8. U.S. Adults Receive Half of Recommended Care; Quality Varies Significantly by Medical Condition Percent of recommended care received Source: E. McGlynn et al. 2003. "The Quality of Health Care Delivered to Adults in the United States,"The New England Journal of Medicine 248(26): 2635–2645.

9. Patients Reporting Any Error by Numberof Doctors Seen in Past Two Years Percent 2005 Commonwealth Fund International Health Policy Survey

10. 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% Number of States with High Proportion of Uninsured Adults Ages 18–64 Is Growing 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: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

11. EFFICIENCY Quality and Costs of Care for Medicare Patients Hospitalized for Heart Attacks, Colon Cancer and Hip Fractures, by Hospital Referral Regions, 2000-2002 Median Relative Resource Use = $25,995 * Indexed to risk-adjusted 1 year survival rate (median = 0.70). ** Risk-adjusted spending on hospital and physician services using standardized national prices. Data: E. Fisher and D. Staiger, Dartmouth College analysis of data from a 20% national sample of Medicare beneficiaries. Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

12. Variation in Annual Total Cost and Quality for Chronic Disease PatientsQuality of Care* and Medicare Spending for Beneficiaries with Three Chronic Conditions, by Hospital Referral Region Best Practice Curve Ft. Lauderdale, FL East Long Island, NY Orange County, CA Greenville, NC Hackensack, NJ Manhattan, NY New Brunswick, NJ Camden, NJ Newark, NJ Saginaw, MI Median Amount Spent per Patient per HRR = $28,694

13. EFFICIENCY International Comparison of Spending on Health, 1980–2004 Average spending on healthper capita ($US PPP) Total expenditures on healthas percent of GDP Data: OECD Health Data 2005 and 2006. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 13

14. EFFICIENCY Percentage of National Health Expenditures Spent on Health Administration and Insurance, 2003 Net costs of health administration and health insurance as percent of national health expenditures * c a b Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

15. The Discourse Has Changed 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

16. We Know The ProblemsNow We Need Solutions

17. Keys to Transforming the U.S. Health Care System • Guarantee affordable health insurance coverage • Implement major quality and safety improvements • Work toward a more organized delivery system that emphasizes primary and preventive care and is patient-centered • Increase transparency and reporting on quality and costs • Expand the use of interoperable information technology • Reward performance on quality and efficiency • Encourage public-private collaboration to achieve simplification, more effective change

18. Guarantee Affordable Health Insurance Coverage 1. Guarantee Affordable Health Insurance Coverage

19. What Are the Most Important Health Care Issuesfor Presidential and Congressional Action? Source: C. Schoen, S.K. How, I. Weinbaum, J.E. Craig, Jr., and K. Davis, “Public Views on Shaping the Future of the U.S. Health System,” The Commonwealth Fund, August 2006.

20. Why Do We Need Universal Coverage? • Waste • cost-shifting • ineffective care (poorer adherence) • duplication • back-end vs. front-end care • Societal benefit It’s Not Just Altruism

21. The Action Now Lies In States • Single payer isn’t likely • Common elements • Expand public programs (cover more poor people) • Require individual participation • Require employer participation

22. Massachusetts Health Plan • MassHealth expansion for children up to 300% Federal Poverty Level; adults up to 100% FPL • 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.

23. California Governor’s Proposal • Individual mandate • Premium subsidies for adults below 250% federal poverty level • Employer offer health insurance or pay 4% of wages into pool • Provider fee assessment (2% of physician revenues to 4% of hospital revenues) • Insurance market regulation • Guaranteed issue • Community rating with age bands • 85 percent minimum medical loss ratio

24. Effective May, 2006: New law in New Jersey allowing persons up to age 30 to be covered under their parents’ insurance

25. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements

26. Richard Shannon, MD Allegheny General Hospital

27. Highmark “Quality Blue” Year 4MRSA

28. Institute for Healthcare Improvement 100K Lives Campaign: Success Story

29. Patient-Centered Hospital Care: Staff Managed Pain, Responded When Needed Help, and Explained Medicines, 2005 Percent of patients reporting “always” * *** **

30. Reid Hospital; Richmond, Indiana