Title: Why Not the Best? A High Performance Health System in Hawaii
1Why Not the Best? A High Performance Health
System in Hawaii
Hawaii Uninsured Project Fall ForumOctober 23,
2006Anne GauthierSenior Policy DirectorThe
Commonwealth Fundwww.cmwf.org
2Presentation Overview
- The Commission on a High Performance Health
System - The National Landscape How are States Performing
Compared to Achievable Benchmarks - State Efforts to Improve Performance
- Legislative Proposals
- Moving Forward
3The 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/ethnicity, health, or
age
The Commission is made up of 19 Commission
members who come with divers practical and policy
expertise in health care delivery, financing, and
access and quality improvement.
4Major Commission Products
- Framework Statement (August 2006)
- Provides sense of urgency to transform U.S.
health care - Defines systemness and stresses need to achieve
it - Depicts major sources of current system failures
- Delineates roles for public and private sectors
- Scorecard Report (September 2006)
- Compares U.S. national average with the best
achieved benchmarks across arenas of quality,
access, efficiency, and equity - Provides a mechanism for monitoring change over
time - Provides a yardstick against which to assess the
effects of existing or proposed policies to
improve performance - The framework and scorecard reports are aligned
in using the same dimensions of high performance
5Commission Conception of High Performing Health
System
LONG, HEALTHY, AND PRODUCTIVE LIVES
EFFICIENCY
SYSTEM CAPACITY TO IMPROVE
6Achieving a High Performance Health System
Requires
- Committing to a clear national strategy and
establishing a process to implement and refine
that strategy - Delivering care through models that emphasize
coordination and integration - Establishing and tracking metrics for health
outcomes, quality of care, access, disparities,
and efficiency
7The National LandscapeHow are States Performing
Compared to Achievable Benchmarks?
C
F
A
D
8Scorecard on US Health System
- The U.S. falls far short on each of the core
goals for health system performance relative to
benchmarks - The US average ratio score is 66 across health
outcomes, quality, access, equity, and efficiency - There are wide gaps across key indicators on
benchmarks largely drawn from achieved rates - The consequence is needlessly lost lives, wasted
health care expenditures, and lower economic
productivity - 50 to 100 Billion annual savings and 100,000 to
150,000 lives - 130 billion in potential productivity gains from
insuring the uninsured (IOM estimate) - Given that the US spends more than any other
country, we should expect to lead on access,
quality and efficiency - Benchmarks provide targets for improvement
- With cost and coverage vital signs moving in the
wrong direction, moving to a high performance
system is of great urgency to secure a healthy
nation
9Mortality Amenable to Health Care
LONG, HEALTHY PRODUCTIVE LIVES
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
Countries age-standardized death rates, ages
074 includes ischemic heart disease DATA
International WHO mortality database from Nolte
and McKee 2003 U.S. 2002 state estimates K.
Hempstead, Rutgers University using Nolte/ McKee
methodology. Methods in technical appendix to
Scorecard Chartpack. SOURCE Commonwealth Fund
National Scorecard on U.S. Health System
Performance, 2006
10Infant Mortality Rate, 2002
LONG, HEALTHY PRODUCTIVE LIVES
Infant deaths per 1,000 live births
International variation
State variation
2001. Data International estimatesOECD Health
Data 2005 State estimatesNational Vital
Statistics System, Linked Birth and Infant Death
Data (AHRQ 2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
11States Vary In Quality of Care
20002001
Quartile Rank
First
Second
Third
Fourth
Note State ranking based on 22 Medicare
performance measures.
Source S.F. Jencks, E.D. Huff, and T. Cuerdon,
Change in the Quality of Care Delivered to
Medicare Beneficiaries, 19981999 to 20002001,
Journal of the American Medical Association 289,
no. 3 (Jan. 15, 2003) 305312.
12Preventive Care Visits for Children, by Top and
Bottom States, Race/Ethnicity, Family Income, and
Insurance, 2003
QUALITY THE RIGHT CARE
Percent of children (ages lt18) received BOTH a
medical and dental preventive care visit in past
year
Data 2003 National Survey of Childrens Health
(HRSA 2005 retrieved from Data Resource Center
for Child and Adolescent Health database at
http//www.nschdata.org).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
13Nursing Homes Hospital Admission and Readmission
RatesAmong Nursing Home Residents, by State, 2000
QUALITY COORDINATED CARE
Hospitalization rates
Re-hospitalization rate (within 3 months
of nursing home admission)
Percent
Percent
Data V. Mor, Brown University analysis of
Medicare enrollment data and Part A claims data
for all Medicare beneficiaries who entered a
nursing home and had a Minimum Data Set
assessment during 2000.
13
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
14Pressure Sores Among High-Risk and Short-Stay
Residents in Nursing Facilities
QUALITY SAFE CARE
Percent of nursing home residents with pressure
sores
State distribution, 2004
By race/ethnicity, 2003
High-risk residents Short-stay residents
White 13 21
Black 17 26
Hispanic 15 25
Asian 12 22
AI/AN 17 23
High-risk residents
Short-stay residents
Data Nursing Home Minimum Data Set (AHRQ 2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
15Percent of Adults Ages 1864 Uninsured by State
ACCESS UNIVERSAL PARTICIPATION
19992000
20042005
NH
NH
ME
WA
VT
NH
ME
WA
VT
ND
MT
ND
MT
MN
MN
OR
NY
MA
WI
OR
NY
MA
ID
SD
RI
WI
MI
ID
SD
RI
WY
MI
CT
PA
NJ
WY
PA
IA
NE
NJ
CT
OH
IA
DE
IN
NE
OH
NV
DE
IN
IL
MD
NV
WV
UT
VA
IL
MD
CO
DC
WV
UT
VA
KS
MO
CA
KY
CO
DC
KS
MO
CA
KY
NC
NC
TN
TN
OK
SC
AR
AZ
NM
OK
SC
AR
AZ
NM
GA
MS
AL
GA
MS
AL
TX
LA
TX
LA
FL
FL
AK
AK
23 or more
HI
HI
1922.9
1418.9
Less than 14
Data Two-year averages 19992000 and 20042005
from the Census Bureaus 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
16States with Highest and LowestAdjusted Health
Plan Premiums, 2002Employee-only adjusted
premiums
Dollars
Adapted from J. Gabel, R. McDevitt, L. Gandolfo
et al., Generosity and Adjusted Premiums in
Job-Based Insurance Hawaii Is Up, Wyoming Is
Down, Health Affairs, May/June 2006 25(3)83243.
17Medicare Hospital 30-Day Readmission Rates, by
Regions, 2003
EFFICIENCY
Rate of hospital readmission within 30 days
Percentiles
Data G. Anderson and R. Herbert, Johns Hopkins
University analysis of 2003 Medicare Standard
Analytical Files 5 Inpatient Data SOURCE
Commonwealth Fund National Scorecard on U.S.
Health System Performance, 2006
18Children with a Medical Home, by Top and Bottom
States, Race/Ethnicity, Family Income, and
Insurance
QUALITY COORDINATED CARE
Percent of children who have a personal doctor or
nurse and receive care that is accessible,
comprehensive, culturally sensitive, and
coordinated
Child had 1 preventive visit in past year
access to specialty care personal doctor/nurse
who usually/always spent enough time and
communicated clearly, provided telephone advice
or urgent care and followed up after the childs
specialty care visits. Data 2003 National Survey
of Childrens Health (HRSA 2005 retrieved from
Data Resource Center for Child and Adolescent
Health database at http//www.nschdata.org).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
19Receipt of All Three Recommended Services for
Diabetics,by Race/Ethnicity, Family Income,
Insurance, and Residence, 2002
EQUITY THE RIGHT CARE
Percent of diabetics (ages 18) who received
HbA1c test, retinal exam, and foot exam in past
year
Insurance for people ages 1864. Urban
refers to metropolitan area gt1 million
inhabitants Rural refers to noncore area lt10,000
inhabitants. Data Medical Expenditure Panel
Survey (AHRQ 2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
20What are States Doing to Transform Health System
Performance?
?
C
F
A
D
21Keys to Transforming the U.S. Health Care System
- Guarantee affordable health care coverage
- Implement major quality and safety improvements
- Work toward a more organized delivery system that
emphasizes patient-centered primary and
preventive care - Increase transparency and reporting on quality
and costs - Expand the use of interoperable information
technology - Reward performance for quality and efficiency
- Encourage public-private collaboration
22State Efforts to Guarantee Affordable Health
Insurance Coverage
1. Guarantee Affordable Health Insurance Coverage
23Hawaii Employer Mandate
- Prepaid Health Care Act of 1974 requires all
private-sector employers to provide health
insurance to full-time employees - Only state to implement an employer mandate
24Massachusetts Health Plan
- 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 - Employers must offer Section 125 Flex Accounts
- Employer mandatory offer, employee mandatory
take-up - Employer assessment (295 if employer doesnt
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.
25Massachusetts Strategies for Coverage Everyone
does their part
Government
Health Care System
- Subsidized insurance
- The Connector
- Uncompensated Care pool reform
- Meet quality and performance standards
- New levels of transparency
- Adjust to payment changes
Expanded Coverage
Employers
Individuals
- Fair Share Assessment
- Free Rider provisions
- Mandatory cafeteria plans
Source Lischko, Amy. October 16, 2006.
Massachusetts Health Reform. NASHP 19th Annual
State Health Policy Conference, Pittsburgh, PA.
26Retaining and Expanding Employer Participation
Maines Dirigo Health
Annual expenditures on deductible and premium
2,738
- New insurance product 1250 deductible sliding
scale deductibles and premiums below 300 poverty
- Employers pay fee covering 60 of worker premium
- Began Jan 2005 Enrollment 14,700 as of 4/30/06
2,188
1,638
1,100
550
0
After discount and employer payment (for
illustrative purposes only).
27Vermont Health Care Affordability Act Enacted
May 2006
- Coverage expansion
- Catamount Health Plans
- Targets individuals w/o access to work-based
coverage - Premium subsidies based on sliding scale up to
300 FPL - Comprehensive benefit package including primary
care, chronic care, acute care other services
- No patient cost-sharing for preventive or chronic
care services - Builds upon Wagners Chronic Care Model
- Financing
- Employer assessment
- Increase in tobacco taxes
- Federal matching funds from Medicaid waiver
28Illinois All-Kids
- Effective July 1, 2006
- Available to any child uninsured for 6 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 lt200 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
29New Jersey Raises Age of Dependent Status for
Health Insurance
- 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
dependents coverage prior to aging out - 200,000 young adults expected to receive coverage
under the law
Millions uninsured, adults ages 1929
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 20012005 Current
Population Surveys)
30Implement Major Quality and Safety Improvements
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
31Puget Sound Health Alliance
- Regional partnership involving employers,
physicians, hospitals, patients, health plans - Working to promote evidence-based medicine
throughout King County, Washington - Participants agree to use evidence to identify
and measure quality health care, then produce
publicly-available comparison reports designed to
help improve health care decision-making
32Work Toward a More Organized Delivery System that
Emphasizes Patient-Centered Primary and
Preventive Care
3. Emphasize Patient-Centered Primary, and
Preventive Care
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
33Utahs Primary Care Network Section 1115
Medicaid Waiver
- Targets uninsured adults (1954) with family
income less than 150 FPL - Provides primary care and preventive care
services - Physician office visits
- Immunizations
- Emergency care
- Lab, X-ray, medical equipment supplies
- Basic dental care
- Hearing vision screening
- Prescription drugs
- Hospitals provide 10 million in charity care for
PCN participants
34Increase Transparency and Reporting on Quality
and Costs
3. Emphasize Primary, Preventive, and
Patient-Centered Care
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
4. Increase Transparency and Reporting on Quality
and Costs
35Wisconsin
- Wisconsin Collaborative for Healthcare Quality
- Voluntary consortium formed in 2003 -- physician
groups, hospitals, health plans, employers
labor - Develops publicly reports comparative
performance information on physician practices,
hospitals health plans - Includes measures assessing ambulatory care, IT
capacity, patient satisfaction access - Wisconsin Health Information Organization
- Coalition formed in 2005 to create a centralized
health data repository based on voluntary sharing
of private health insurance claims, including
pharmacy laboratory data - Wisconsin Dept of Health Family Services and
Dept of Employee Trust Funds will add data on
costs of publicly paid health care through
Medicaid
36Expand the Use of Interoperable Information
Technology
3. Emphasize Primary, Preventive, and
Patient-Centered Care
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
5. Expand the Use of Interoperable Information
Technology
4. Increase Transparency and Reporting on Quality
and Costs
37Information ExchangeStates Leading the Way
- New York State Health Information Technology
(HIT) initiative - Under the Health Care Efficiency and
Affordability Law for New Yorkers, 52.9 million
awarded to 26 regional health networks to expand
technology in NY health care system and support
clinical data exchange Commonwealth
Fund-supported evaluation underway
Source Evolution of State Health Information
Exchange, AHRQ, Publication No. 06-0057, January
2006.
38Reward Performance for Quality and Efficiency
3. Emphasize Primary, Preventive, and
Patient-Centered Care
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
5. Expand the Use of Interoperable Information
Technology
4. Increase Transparency and Reporting on Quality
and Costs
6. Reward Performance for Quality and Efficiency
39Building Quality Into RIte CareHigher Quality
and Improved Cost Trends
- 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
Cumulative Health Insurance Cost Trend Comparison
Percent
RI Commercial Trend
RIte Care Trend
Source Silow-Carroll, Building Quality into
RIte Care, Commonwealth Fund, 2003. Tricia Leddy,
Outcome Update, Presentation at Princeton
Conference, May 20, 2005.
40Encourage Public-Private Collaborationto Achieve
Simplification, More Effective Change
3. Emphasize Primary, Preventive, and
Patient-Centered Care
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
7. Encourage Public-Private Collaboration
to Achieve
Simplification, More Effective
Change
5. Expand the Use of Interoperable Information
Technology
4. Increase Transparency and Reporting on Quality
and Costs
6. Reward Performance for Quality and Efficiency
41Minnesota Smart-Buy Alliance
- Initiated in 2004 alliance between state,
private businesses labor groups - Purchase health insurance for 70 of state
residents 3.5 million people - Pool purchasing power to drive value in health
care delivery system - Set uniform performance standards, cost/quality
reporting requirements technology demands - Four key strategies
- 1. Reward or require best in class
certification - 2. Adopt and utilize uniform measures of quality
and results - 3. Empower consumers with easy access to
information - 4. Require use of information technology
42Expanding Coverage is Only One Piece of the Puzzle
3. Emphasize Primary, Preventive, and
Patient-Centered Care
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
7. Encourage Public-Private Collaboration
to Achieve
Simplification, More
Effective Change
5. Expand the Use of Interoperable Information
Technology
4. Increase Transparency and Reporting on Quality
and Costs
6. Reward Performance for Quality and Efficiency
43Several States Attempting Comprehensive Health
Reform
- Maine, Maine and Vermont have quality initiatives
built into coverage expansions - Maine
- Created Maine Quality Forum to advocate for high
quality health care and help each Maine citizen
make informed health care choices. - Massachusetts
- Cost and Quality Council formed
- Vermont
- Quality improvement initiatives
- Public-private collaboration
- Collection of health care data from all payers
- Provides rules to publicly report price quality
information
44Rhode IslandFive-Point Strategy
- 5 point strategy
- Creating affordable health plans for small
businesses individuals - Increasing wellness programs
- Investing in health care technology
- Developing centers of excellence
- Leveraging the states purchasing power
- RI Quality Institute
- Non-profit coalition including hospitals,
providers, insurers, consumers, business,
academia government - Partnered with SureScripts to implement
state-wide electronic connectivity between all
retail pharmacies and prescribers in the state - Health Information Exchange Initiative
- Statewide public/private effort
- AHRQ contract 5 yr/ 5M
- Connecting information from physicians,
hospitals, labs, imaging other community
providers
45- National Legislative Proposals to Facilitate
State Innovations
46H.R. 5684 Health Partnership Through Creative
Federalism Act
Rep. Tammy Baldwin (D-WI)
Rep. Tom Price (R-GA)
- Real cooperation from across the aisle proposed
by Baldwin and Price with the support of both the
Heritage Foundation and the Brookings Institute
National Governors Association also had role in
drafting the bill - Requests that states submit proposals for state
health care coverage expansion and improvements
in quality, efficiency, cost-effectiveness, and
the appropriate use of health information
technology - State proposals defined as statewide, multi-state
or limited to certain regions - Establishes a Commission to
- Request and review proposals and submit a list it
recommends for approval to Congress - Report to the public concerning progress made by
states - Make recommendations for minimizing negative
effects of state programs on national
employer, provider organizations, insurer
47S. 2772 Health Partnership Act
Senator George Voinovich (D-WI)
Senator Jeff Bingaman (D-NM)
- Provides states with grants to carry out
innovative state health programs, with priority
given to programs most likely to expand coverage
and improve access - Establishes a Commission to
- provide states with reform options for state
health care expansion and improvement programs - establish minimum performance measures and goals
with respect to coverage, quality, and cost of
state programs - review state applications and determine whether
to submit a state proposal to Congress
48Moving Forward
States Can Lead the Way
49What States Can Do to Promote a High Performance
Health System Strategies to Expand Coverage
- Design shared responsibility strategy to include
state, employers and individuals - Expand public programs
- Provide financial assistance to low income
workers and employers to afford coverage - Require employers to offer Section 125 benefit
plans - Mandate individuals to purchase coverage
- Require employers to offer and employees to take
up insurance - Require insurers to raise age limit for
dependents - Pool purchasing power and promote new benefit
designs to make coverage more affordable - Develop reinsurance programs to make coverage
more affordable in the small group and individual
markets -
50What States Can Do to Promote a High Performance
Health System Strategies to Improve Quality and
Efficiency
- Promote evidence-based medicine
- Promote effective chronic care management
- Promote transitional care post-hospital discharge
- Encourage data transparency and reporting on
performance - Promote/practice value-based purchasing
- Promote the use of health information technology
- Promote wellness and healthy living
- Encourage selection of medical home and improved
access to primary care and preventive services - Simplify and streamline public program
eligibility and re-determination
51Challenge for Hawaii Continue the commitment to
universal coverage AND choose another dimension
on which to lead!
52Selected Commonwealth Fund Publications
- The Commonwealth Fund Commission on a High
Performance Health System, Framework for a High
Performance Health System for the United States,
The Commonwealth Fund, August 2006 - The Commonwealth Fund Commission on a High
Performance Health System, Why Not the Best?
Results from a National Scorecard on U.S. Health
System Performance, The Commonwealth Fund,
September 2006 - S. Silow-Carroll and F. Pervez, States in Action
A Quarterly Look at Innovations in Health Policy,
The Commonwealth Fund, Summer 2006, Vol. 5. - Forthcoming State Scorecard on Health System
Performance
All publications are available at
http//www.cmwf.org
53Visit the Fund at
Acknowledgements
Stephen C. Schoenbaum Executive Vice President
for Programs
Karen Davis President
Cathy Schoen Senior Vice President
for Research and Evaluation
Alyssa Holmgren Research Associate
Ilana Weinbaum Program Associate
Sabrina How Research Associate