THE
COMMONWEALTH
FUND
A Need to Transform the U.S. Health
Care System: Improving Access,
Quality, and Efficiency
Karen Davis
President, The Commonwealth Fund
National Association of Community Health Centers
Plenary Address
March 27, 2006
[email protected]
www.cmwf.org
Need for Better Access, Higher Quality, and
Greater Efficiency
2
• The U.S. health system fails to provide access to care for
all
– 46 million uninsured
– 16 million adults underinsured
• The U.S. health system fails to reliably deliver high
quality care to all
– Only 55 percent of recommended care delivered
– Only half of adults received recommended preventive
care
– One-third of sicker adults report medical, medication,
or lab test error in past two years
• The U.S. health system is costlier than any other
country, but fails to deliver superior value for money
spent
THE
COMMONWEALTH
FUND
3
Ten Keys to Transforming the U.S.
Health Care System
1. Agree on shared values and goals
2. Organize care and information around the
patient
3. Expand the use of information technology
4. Enhance the quality and value of care
5. Reward performance
6. Simplify and standardize
7. Expand health insurance and make
coverage automatic
8. Guarantee affordability
9. Share responsibility for health care
financing
10. Encourage collaboration
THE
COMMONWEALTH
FUND
4
Community Health Centers
Can Lead the Way
Within own organizations
•
Organize care and information around the patient
•
Expand the use of information technology
•
Enhance the quality and value of care
By joining with others for policy change
•
Support Medicaid, CHIP, and Medicare
•
Expand health insurance and make coverage
automatic and affordable
•
Embrace change – transparency, public reporting,
pay for performance
THE
COMMONWEALTH
FUND
5
Community Health Centers:
Key Role in Caring for Most
Vulnerable
THE
COMMONWEALTH
FUND
6
Health Center Patients Are Predominantly
Low-Income, and Most are Uninsured or Have
Medicaid
Patients by Poverty Level
Patients by Insurance Status
Over 200%
poverty
151–200% 10%
Other
public
3%
poverty
6%
101–150%
poverty
14%
Private
15%
Uninsured
39%
Medicare
7%%
100%
poverty
and below
69%
Source: Bureau of Primary Health Care, 2003 Uniform Data System
Medicaid/
SCHIP
36%
THE
COMMONWEALTH
FUND
Racial and Ethnic Minorities Make Up
Two-Thirds of all Health Center Patients
7
African
American
24%
White
36%
American Indian/
Alaska Native
1%
Asian/
Hispanic/
Pacific
Latino
Islander
35%
3%
THE
COMMONWEALTH
FUND
Source: Bureau of Primary Health Care, 2002 Uniform Data System
8
Nearly One-Third of Health Center Patients
Prefer Languages Other than English
Percent of users preferring languages other than English
50%
40%
30%
20%
18%
19%
1997
1998
27%
28%
29%
30%
2000
2001
2002
2003
23%
10%
0%
1999
THE
COMMONWEALTH
FUND
Source: 1997-2002 Uniform Data System, BPHC, HRSA, DHHS.
9
Proportion of Vulnerable Populations at
Health Centers and in the U.S.
Health centers,
2004
U.S. Population,
2003*
Less than 100%
poverty#
71%
13%
Less than 200%
poverty
91
31
Uninsured
40
16
Medicaid
36
12
64
32
Income
Insurance status
Minority
* Most recent year available.
# For a family of three, $15,260 annual income in 2003 and %15,670 for in 2004.
Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC
Report, August 2005.
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COMMONWEALTH
FUND
10
Growth in Health Center Patients by
Insurance Status, 1999-2004
In millions
6
4.9
5
4
3
2
3.7
2.9
3.9
4.0
4.4
4.0
3.2
4.4
5.3
4.7
Medicaid
3.6
Private
1.7
1.8
1.9
1.4
1.5
1.6
1 0.7
0.7
0.7
0.8
0.9
1.0
0.3
0.4
0.4
0.3
0.3
2000
2001
2002
2003
2004
0
0.3
1999
Uninsured
Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC
Report, August 2005.
Medicare
Other public
THE
COMMONWEALTH
FUND
11
Community Health Centers:
A Leader in High Performance Care
THE
COMMONWEALTH
FUND
12
Increased Access of Uninsured to Care
Health Center
Patients
• 25% delayed care
due to costs
Non-Health Center
Patients
• 55% delayed care
due to costs
• 16% went without
needed care
•
30% went without
needed care
• 12% could not fill
Rx
•
24% could not fill
Rx
Source: Politzer, R., et al. 2001. “Inequality in America: The Contribution of Health Centers in
Reducing and Eliminating Disparities in Access to Care.” Medical Care Research and Review
58(2):234-248.
THE
COMMONWEALTH
FUND
13
Ambulatory Care Sensitive Events by
Regular Source of Care
Number of ACS events per 100 persons
75
Health centers
Other providers
50
38
26
25
6
8
0
ACS admissions
ACS emergency visits
Source: M. Falik et al., “Comparative Effectiveness of Health Centers as Regular Source of Care,”
Journal of Ambulatory Care Management 29, no. 1 (November 26, 2005): 24-35.
THE
COMMONWEALTH
FUND
Pap Tests by Race:
Women Served by Community Health
Centers Compared to National Sample
14
CHC
NHIS Comparison Group
89
All Women
75
86
Hispanic
80
85
White Non-Hispanic
73
94
Black Non-Hispanic
82
89
Other
66
0
20
40
60
80
Source: Dan Hawkins, “Improving Minority Health and Reducing Disparities through the
Health Disparities Collaboratives of America’s Community Health Centers,” Presentation to NAPH
(June 24, 2005) Santa Fe, NM.
100
THE
COMMONWEALTH
FUND
15
Self-Reported Quality Assessment of
Care Received at Health Centers
Percent
75
63
1993
55
50
41
2001
36
25
4
1
0
Very
satisfied
Satisfied
Dissatisfied
0
1
Very
dissatisfied
THE
COMMONWEALTH
FUND
Source: PEERS Report, NACHC analysis of PEERS, 1993-2001
16
Wait Times at Health Centers, 1993–2001
Percent of health center patients
60
1993
50
2001
40
30
20
10
0
Under 15
minutes
15-30
minutes
31-59
minutes
1-3 hours
3+ hours
THE
COMMONWEALTH
FUND
Source: PEERS Report, NACHC analysis of PEERS, 1993-2001
17
Community Health Centers:
Assuming a Leadership Role in A
High Performance Health System
THE
COMMONWEALTH
FUND
Actions Community Health Centers Can
Take to Promote High Performance
18
• Organizing care and information around
the patient
– Patient-centered care
– Medical home or advanced primary care
practice
– Advanced access
• Information technology
• Enhancing the quality and value of care
– Chronic disease management
– Coordination of care
THE
COMMONWEALTH
FUND
Attributes of Patient-Centered Primary
Care
•
19
Superb access to care
–
•
Quick appointments, short waiting times, accessible off-hours coverage,
e-mail and telephone consultations
Patient engagement in care
–
•
Information for patients on treatment and self-management plans,
preventive and follow-up care reminders, access to medical records,
assistance with self-care
Clinical information systems
–
•
Patient registries; monitor adherence to treatment; lab and test results;
decision support
Care coordination
–
•
Coordination of specialist care, systems/processes to prevent errors in
transitions, post-hospital follow-up
Integrated and comprehensive team care
–
•
Excellent communication among physicians, nurses, and other health
professionals, and appropriate use of skills of all team members
Routine patient feedback to doctors
–
•
Learn from patient-surveys and feedback
Publicly available information
–
Patients have accurate, timely, complete information on physicians andTHE
COMMONWEALTH
other clinicians providing care
FUND
20
Insurance Status and
Continuity of Care with a Regular Doctor
Same doctor for
more than 5 years
18%
No regular doctor
54%
No regular doctor
19%
Same doctor for
more than 5
years
34%
Same doctor for
fewer than 5 years
28%
Uninsured adults (full or part year)
Same doctor for
fewer than 5 years
47%
Insured adults
Source: Karen Davis, Stephen C. Schoenbaum, Karen Scott Collins, Katie Tenney, Dora L. Hughes,
and Anne-Marie J. Audet, Room for Improvement, The Commonwealth Fund, April 2002.
THE
COMMONWEALTH
FUND
21
People in Community Health Centers Who
Have a Usual Source of Care, 2002
Percent
100
98
98
98
75
50
25
0
Non-hispanic white African American
Hispanic
Source: AHRQ, “Focus on Federally Supported Health Centers,” National Healthcare Disparities
Report, 2004. http://www.qualitytools.ahrq.gov/disparitiesReport/browse/browse.aspx?id=4981
THE
COMMONWEALTH
FUND
Minorities Without a Regular Doctor
Are More Likely to Use Emergency Room
for Care
22
Percent reporting emergency room or no regular place of care
No Regular Doctor
Regular Doctor
27%
24%
30%
16%
14%
15%
4%
7%
7%
4%
0%
White
African
American
Hispanic
Asian
American
Source: K.S. Collins et al., “Diverse Communities, Common Concerns: Assessing Health Care
Quality for Minority Americans,” The Commonwealth Fund, March 2002
THE
COMMONWEALTH
FUND
In U.S., Canada Adults Less Likely to Be Able to
See Physician Same Day and More Likely to
Substitute ER for Regular Physician Care
23
Access to Doctor When Sick or Needed Medical Attention
Percent
75
60
54
50
41
27
33
25
0
9
AUS CAN NZ UK US
Same day appointment
18
7
16
6
AUS CAN NZ UK US
Went to ER for condition
that could have been
treated by regular doctor if
available
Source: 2004 Commonwealth Fund International Health Policy Survey
THE
COMMONWEALTH
FUND
Primary Care Development Corporation
Primary Care Clinic Redesign Collaborative:
24
Before Redesign
148 Minutes, 11 Steps
FRONT
DESK
CASHIER
WAITING
ROOM
NURSING
STATION
BATHROOM
NURSING
STATION
EXAM ROOM
WAITING
ROOM
LAB
FRONT
DESK
FRONT
DESK
CLERK
EXIT
After Redesign
50 Minutes, 4 Steps
FRONT
DESK
CASHIER
WAITING
ROOM
EXAM
ROOM
EXIT
THE
COMMONWEALTH
FUND
Source: Pamela Gordon, M.A., and Matthew Chin, M.P.A., Achieving a New Standard in Primary Care for LowIncome Populations: Case Study 1: Redesigning the Patient Visit, The Commonwealth Fund, August 2004
25
The PCDC Track Record
Program
Teams
Outcomes
Redesign
(7 Collabs)
77
• Cycle time: 109 to 53 minutes
• “Waiting around” time: 106 to 0minimum.
• Visits/hour/provider: 2.9 to 3.2
Advanced
Access
(5 Collabs)
24
• Days for next available appt: 21 to
range of 0-5
• No show rate: 50% to 38%
Rev Max
(3 Collabs)
23
• 1st 5 teams: $512,000
• 2nd 4 teams: $2.4M (incl. 1 large
hospital)
• 3rd 14 teams: $2.2 (all CHCs)
Marketing
(3 Collabs)
13
• 14% increase in patients
Total
137
THE
COMMONWEALTH
FUND
Center for Shared Decision-Making
Dartmouth-Hitchcock Medical Center
26
• Provides tools to assist
with health care decisions
(e.g., videotapes, booklets,
websites)
• Provides follow-up
counseling with skilled staff
• Seeks to be a prototype for
health care systems
nationwide
Kate Clay, BA, MSN,
Program Director
THE
COMMONWEALTH
FUND
27
Patient Access to Personal Health Records
Do not have access to own medical records but would like to
Percent
Have access to own medical records
100
80
82
80
75
40
50
25
48
40
34
AUS
CAN
88
70
35
37
42
45
51
28
0
NZ
UK
US
THE
COMMONWEALTH
FUND
Source: The Commonwealth Fund 2004 International Health Policy Survey.
Electronic Access to Patient Test Results &
Medical Records (EMRs), and Electronic
Ordering, by Practice Size
28
Percent who currently “routinely/occasionally” use the following
100
1 Physician
10–49 Physicians
50+ Physicians
87
75
50
2–9 Physicians
61
66
57
36
23
25
37
35
13
46
25
14
0
Electronic access to
Electronic medical
test results
records
Electronic ordering*
* Electronic ordering of tests, procedures, or drugs.
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
THE
COMMONWEALTH
FUND
29
E.Wagner, MD
THE
COMMONWEALTH
FUND
30
Health Disparities Collaboratives
• Goal: Implement in all 1,000 health centers by 2006
– 600 health centers nationwide participating
– 250,000+ health center patients with chronic
disease enrolled in electronic registries
• Chronic Care Model:
– Use of evidence-based care
– Assure care continuity
– Effectively involve patients in self-management
– Completely re-design system to emphasize health
• Collaboratives
– Training and technical assistance
– Quality Improvement infrastructure
– Partnerships at the local, state, and national level
• Commonwealth Fund co-funding evaluation with
AHRQ – Bruce Landon Harvard
THE
COMMONWEALTH
FUND
New York City Health and Hospitals Corporation:
Diabetes Outcomes: HBA1c, Blood Pressure
Mean A1C <7
• Average A1C<7
increased from
30% to 42%
Se
p0
O 3
ct0
No 3
v0
De 3
c0
Ja 3
n0
Fe 4
b0
M 4
ar
Ap 04
r-0
M 4
ay
-0
Ju 4
n04
Ju
lAu 04
g0
Se 4
p04
Percent
60
50
40
30
20
10
0
31
60
50
40
30
20
10
0
• 31% with BP
130/80 at
baseline,
increased to 57%
Se
p0
O 3
ctNo 03
v0
De 3
c0
Ja 3
n0
Fe 4
b0
M 4
ar
Ap 04
r-0
M 4
ay
-0
Ju 4
n0
Ju 4
l-0
Au 4
g04
percent
Mean BP <130/80
Source: Karen Scott-Collins, MD, MPH, Deputy Chief Medical Officer, Health Care Quality and
Clinical Services, New York City Health and Hospitals Corporation
THE
COMMONWEALTH
FUND
Physicians’ Participation in Redesign and
Collaborative Activities, by Practice Size
32
Percent indicating involvement in redesign and collaborative efforts
Total
1 Physician
2–9 Physicians
10–49 Physicians
50+ Physicians
100
43
50
35
34
24
50
47
33
32
39
20
0
Redesign Efforts
Collaborative Efforts*
* Indicates physicians who responded yes to participating in local, regional, or national collaboratives
in the past 2 years.
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
THE
COMMONWEALTH
FUND
33
Health Policy:
Need for Leadership
• Federal budget deficits harmful to U.S.
economy in long-term
• Tax revenues as percent of GDP at 40 year
low, yet further tax cuts are on the table
• Cuts to Medicaid have potential to harm
access to health care for low-income
beneficiaries; savings not used to expand
coverage of uninsured
• Medicare privatization contributes to higher,
not lower, costs and budget outlays; no
solution to Medicare long-term fiscal problems
• Real solutions to grappling with nation’s
health care problems not being considered
THE
COMMONWEALTH
FUND
34
Tax Revenues at Lowest Percent of
GDP in 40 Years
Percent of GDP
Revenues
24
23
22
21
Outlays
Actual
Projected
Average
Outlays,
1962-2004
20
19
18
17
16
Average
Revenues,
1962-2004
15
1962 1967 1972 1977 1982 1987 1992 1997 2002 2007 2012
Note: Actual 1962–2004; Projected 2005–2015.
Source: Congressional Budget Office, The Budget and Economic Outlook: Fiscal Years 2006 to 2015,
January 2005.
THE
COMMONWEALTH
FUND
Average Annual Medicaid Spending Growth
Per Enrollee Lower Than Private Health
Spending, 2000–2003
35
Percent average annual growth
14
12.6
12
10
8
9.0
6.9
6
4
2
0
Medicaid acute care
Health care spending
Monthly premiums for
spending per enrollee
per person with
employer-sponsored
private coverage
insurance
Source: J. Holahan and A. Ghosh, “Understanding the Recent Growth in Medicaid Spending, 2000–
2003,” Health Affairs Web Exclusive, January 26, 2005; B.C. Strunk and P.B. Ginsburg, “Trends:
Tracking Health Care Costs: Trends Turn Downward In 2003,” Health Affairs Web Exclusive, June 9,
2004; Kaiser/HRET, Employer Health Benefits 2003 Annual Survey, 2003
THE
COMMONWEALTH
FUND
36
Higher Deductibles Associated with
Greater Access Problems
Percent of adults ages 21-64 who have delayed
or avoided getting health care due to cost
60
Comprehensive
HDHP
CDHP
48
42
40
40
35
31
31
26
20
21
17
0
Total
Health Problem** <$50,000 Annual
Income
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam);
HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP =
plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.
**Health problem defined as fair or poor health or one of eight chronic health
conditions.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
• Administration policy
provides for:
– Tax incentives for the
purchase of high
deductible health plans
– Tax credits for lowincome uninsured
individuals and families
• Minor effect on uninsured
(e.g. 2-3 million out of 46
million uninsured)
• Almost no effect on rising
health care costs
• Likely to increase
“underinsurance” and pose
barriers to care for lowincome and chronically
ill
THE
COMMONWEALTH
FUND
37
Percent of Adults Ages 18–64 Uninsured
by State
1999–2000
2003–2004
WA
VT
NH ME
NH
WA
ND
MT
VT
MT
MN
OR
ID
NY
WI
SD
MI
WY
PA
IA
NE
CA
OH
IN
NV
UT
IL
CO
MA
KS
MO
WV
VA
KY
NJ
RI
CT
MN
OR
ID
MI
PA
IA
NE
CA
IL
CO
KS
MO
AZ
NM
MS
TX
AL
DE
MD
DC
NC
AZ
GA
NM
OK
SC
AR
MS
LA
TX
AL
GA
LA
FL
AK
VA
NJ
RI
CT
TN
SC
AR
WV
KY
TN
OK
OH
IN
NV
UT
MA
NY
WI
SD
WY
DE
MD
DC
NC
ME
ND
FL
AK
HI
HI
24% or more
19%–23.9%
14%–18.9%
Less than 14%
Source: Two-year averages 1999–2000 and 2003–2004 from the Census Bureau’s March 2000, 2001
and 2004, 2005 Current Population Surveys. Estimates by the Employee Benefit Research Institute.
THE
COMMONWEALTH
FUND
38
Without Insurance it Is Difficult to Obtain
Specialized Care
Uninsured patients
Can provide all
necessary services
using health center's
resources
Insured patients
Can obtain nonemergency
admissions
Can obtain
specialty referrals
0
20
40
60
80
Source: M.K. Gusmano, G. Fairbrother, and H. Park, “Exploring the Limits of the Safety Net:
Community Health Centers and Care for the Uninsured,” Health Affairs 21, no. 6 (Nov./Dec. 2002):
188–94.
100
THE
COMMONWEALTH
FUND
Proportion of U.S. Physicians Providing
Charity Care Is Declining
39
Percent
100
76.3
75
#
71.5
68.2 #*
50
25
0
1996-97
2000-01
2004-05
* Change from 2000-01 is statistically significant at p<.05
# Change from 1996-977 is statistically significant at p<.05
Source: P.J. Cunningham and J.H. May, “A Growing Hole in the Safety Net: Physician Charity Care
Declines Again,” Center for Studying Health System Change, Tracking Report No. 13, March 2006.
THE
COMMONWEALTH
FUND
40
Retaining and Expanding Employer
Participation: Maine’s Dirigo Health
Annual expenditures on deductible and premium
$3,000
Deductible amount
$2,738
Employee share of annual premium
$2,500
$2,188
1250
$2,000
$1,638
$1,500
1000
• Employers pay fee
covering 60% of
worker premium
$1,100 750
$1,000
$500
$0
$550
$0
0
MaineCare
250
300
<150%
500
600
<200%
888
<250%
1188
<300%
• New insurance
product; $1250
deductible; sliding
scale deductibles
and premiums
below 300% poverty
1488
• Began Jan 2005;
Enrollment 11,000
as of 10/20/05
>300%
THE
COMMONWEALTH
FUND
* After discount and employer payment (for illustrative purposes only).
41
Pay for Performance Programs
• There are almost 90 pay-for-performance programs
across the U.S.
– Provider driven (e.g., Pacificare)
– Insurance driven (e.g., BC/BS in MA)
– Employer driven (e.g., Bridges to Excellence –
Verizon, GE, Ford, Humana, P&G, and UPS)
– Medicare
• 2003 Medicare Rx legislation demonstrations of
Medicare physicians a per-beneficiary bonus if
specified quality standards are met
– Medicaid
• RIte Care will pay about 1% bonus on its
capitation rate to plans meeting 21 specified
performance goals
• 4 other states built performance-based incentives
into Medicaid contracts – UT, WI, IO, MA
• Evaluation of impact still pending
Source: Leapfrog report for Commonwealth Fund; additional information available at
http://www.leapfroggroup.org/
THE
COMMONWEALTH
FUND
42
Building Quality Into RIte Care
Higher Quality and Improved Cost Trends
Percent
160
Cumulative Health
Insurance Rate Trend
Comparison
140
120
100
RI Commercial Trend
80
60
• Improved access,
medical home
– One third reduction
in hospital and ER
– Tripled primary care
doctors
– Doubled clinic visits
40
20
• Quality targets and $
incentives
RIte Care Trend
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
0
• 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.
THE
COMMONWEALTH
FUND
43
Take Away Messages
• Closing gaps in insurance coverage is the number one
priority action to improve care for vulnerable populations
– Support Medicaid funding
– Support expansion of insurance coverage
– Support adequate funding of primary care capacity in
low-income underserved communities
• Promote patient-centered primary care
– Make it easy to get appointments and obtain care
– Shared decision-making can help improve and
coordinate care, and engage patients as active
partners in their care
• Invest in information technology
• Invest in chronic care quality improvement
– Share best practices
– Join learning collaboratives to improve care
• Embrace transparency, public reporting, and pay for
performance
THE
COMMONWEALTH
FUND
44
Thank You!
•
Stephen C. Schoenbaum, M.D., Executive Vice
President and Executive Director, Commonwealth
Fund Commission on a High Performance Health
System
•
Anne Gauthier, Senior Policy Director,
Commonwealth Fund Commission on a High
Performance Health System
•
Alyssa L. Holmgren, Research Associate,
Commonwealth Fund
Visit the Fund at: www.cmwf.org
THE
COMMONWEALTH
FUND
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A Need to Transform the U.S. Health Care System: …