Achieving%20a%20High%20Performing%20Health%20Care%20System:%20Applying%20Lessons%20from%20Other%20Countries%20to%20U.S.%20Health%20Care

1
Achieving a High Performing Health Care
SystemApplying Lessons from Other Countries to
U.S. Health Care

• David C. Dale MD, FACP
• J. Fred Ralston, Jr. MD, FACP
• Robert B. Doherty
• American College of Physicians
• Based on a Presentation to the National Congress
  on the Un and Underinsured
• December 11, 2007

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Introduction

• What is the American College of Physicians?
• 124,000 Doctors of Internal Medicine and Medical
  Students
• The Second Largest Medical Organization in the
  USA
• The Largest Medical Specialty Society

3
What Did We Do?

• Analyzed the US Health Care System
• Evaluated According to Commonwealth Fund Criteria
  for Measuring Performance
• Analyzed Health Care Systems in 12 Other
  Countries
• Compared the US Health Care System to Systems in
  Other Countries
• Determined Lessons From Other Countries
• Issued Recommendations for Achieving a High
  Performance Health Care System

4
Why Did We Do It?

• ACP has Advocated for Universal Health Insurance
  Coverage Since 1990
• Previous Efforts By ACP and Others Have Focused
  on Improving Specific Aspects of Health Care
• Systemic Changes Are Needed
• Goal to Achieve a High Performance Health Care
  System With Universal Access
• Lessons Can Be Learned from Successful Health
  Care Systems in Other Countries

5
The Cost of Health Care in the US

• National Health Expenditures in 2005
• 2.0 Trillion
• 6,697 per person
• 16 of GDP
• Health Insurance Costs Continue to Rise
• Health Spending is Rising Faster Than Inflation
  and Economic Growth
• Employers Are Reducing or Dropping Coverage
• Health Spending is Projected to Reach 4.0
  Trillion (20 of GDP) by 2015

6
Paying for Health Care in the US
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Health Insurance Coverage in the US

• 250 Million Have Health Insurance (84.2)
• 47 Million (15.8) Uninsured All Year
• 89.5 Million (34.6) Uninsured 1 Month or More
• Another 16 Million Under-Insured

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People Without Health Insurance are

• Less Likely to Receive Preventive Services and
  Medications
• Less Likely to Have Access to Regular Care by a
  Personal Physician
• Less Able to Obtain Needed Health Care Services
• More Likely to Suffer Complications for
  Preventable Illnesses
• More Likely to Die Prematurely

9
Chronic Health Conditions

• 120 Million Americans (45) Have at Least 1
  Chronic Condition
• 60 Million Have Multiple Chronic Conditions
• 83 of Medicare Beneficiaries Have 1 or More
• 23 of Medicare Have 5 or More
• By 2015, 150 Million Will Have at Least 1
  Chronic Condition

10
The Increasing Elderly Population
Source U.S. Census Bureau, U.S. Interim
Projections by Age, Sex, Race, and Hispanic
Origin, lthttp//www.census.gov/ipc/www/usinterimp
roj/gt
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As Patients Age They Require More Visits to the
Doctor
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Physician Workforce

• The Supply of Primary Care Physicians Will Not
  Keep Pace with the Aging Population
• Already Anecdotal Evidence of Shortages
• As the Population Over Age 65 Increases More
  Doctors Will be Needed
• High Student Debt and a Dysfunctional Payment
  System are Deterring Physicians from Primary Care
  Careers
• The Physician Workforce Is Also Aging 250,000
  Active Physicians Are Over Age 55

13
Interest in Entering Primary Care has been
Declining Among Graduating Seniors(Percentages
1999-2006)
Source AAMC Medical School Graduation
Questionnaires All School Reports 2000-2006,
Choice of Specialty/Subspecialty.
http//www.aamc.org/data/gq/allschoolsreports/2006
.pdf
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Equity and Utilization

• Wide Variations in Costs
• Wide Differences in Volume and Intensity of
  Services Among Areas
• Outcomes No Better in High Cost Areas
• Disparities in Access and Quality Based on Race
  and Income

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The System is Costly and Inefficient

• Payers Are Straining to Reduce Costs
• Cost Sharing Increasing
• Rise of Consumer-Directed Health Plans
• Increasing Out-of-Pocket Costs
• High Administrative Costs
• High Regulatory Burden

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A big caveat

• Any solution for the United States will be unique
  to our political and social culture,
  demographics, and form of government
• Larger and more diverse population
• Tradition of individualism and distrust of the
  federal government
• Constitution limits the power of the federal
  government, requires that authority be shared
  between federal and state governments, and
  protects commercial and individual free speech
• Deeply rooted system of employer-based coverage,
  tied to a powerful industry invested in
  maintaining private insurance and employer-based
  coverage

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So why study other countries experiences?

• Goal should not be to replicate other countries
  experiences
• But to identify approaches that the evidence
  shows are more likely to be effective
• So that they can inform the political debate in
  the United States
• And be adapted to the unique circumstances in the
  U.S.

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Lesson All high performing systems have
universal coverage

• Universal every person is guaranteed, by law,
  access to affordable coverage through a public or
  private plan and is required to obtain coverage
• Some have a system funded solely by the national
  or provincial governments (single payer)
• Others use a mix of public and private funding
  (pluralistic) coverage is compulsory and
  guaranteed

Canada UK Japan Taiwan
Australia Belgium Denmark France Germany
Netherlands New Zealand Switzerland
Australia, Belgium, Denmark, France, Germany,
Netherlands, New Zealand and Switzerland
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Lesson Global budgets and price controls can
restrain costs but can have negative consequences
Canada Germany New Zealand Taiwan United Kingdom

• Global budgets can restrain costs. but do not
  improve efficiency unless the budget is
  reasonable and the target region is small enough
  to motivate individual providers
• Price controls can restrain costs, but may lead
  to
• delays for elective procedures, cost-shifting and
  
• creation of parallel private sector markets

Belgium Canada Japan UK
Japan New Zealand UK
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Recommendation U.S. must provide universal
coverage

• Guarantee by law that all people within the
  United States have equitable access to
  appropriate health care without unreasonable
  financial barriers
• Health insurance coverage and benefits should be
  continuous and not dependent on place of
  residence or employment status
• U.S. should consider adopting either a single
  payer or pluralistic model with guaranteed
  coverage

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Single payer or pluralistic systems are both
capable of achieving universal coverage

• Single-payer systems can achieve universal access
  to health care without barriers based on ability
  to pay
• Pluralistic systems can assure universal access,
  but must provide (1) a legal guarantee that all
  individuals have access to coverage and (2)
  sufficient government subsidies and funded
  coverage for those who cannot afford to purchase
  coverage through the private sector

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Either has tradeoffs that the public will need to
weigh in making a choice

• Single-payer more equitable, lower
  administrative costs, lower per capita health
  care expenditures, high levels of
  consumer/patient satisfaction and high
  performance on measures of quality and access
• May create shortages of services, delays in
  obtaining elective procedures and limit
  individuals choices
• Pluralistic with guaranteed coverage allows
  individuals the freedom to purchase supplemental
  coverage and services
• More likely to result in inequities in coverage
  and higher administrative costs

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Lesson Primary care is the foundation of high
performing delivery systems

• Societal investment in medical education, can
  help achieve a workforce that has the right
  proportion of primary care physicians and
  specialists, is well-trained, and is large enough
  to assure access
• Investment in primary and preventive care can
  result in better health outcomes, reduce costs,
  and help assure an adequate supply of primary
  care physicians
• These efforts can be enhanced by assuring that
  all residents have equitable access to a
  patient-centered medical home model

France Germany United Kingdom
Australia, Canada, Denmark France NetherlandsNew
Zealand Switzerland UK
Denmark
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Recommendation U.S. policy should support the
value of primary care

• Federal government should intervene to avert the
  impending catastrophic shortage of primary care
  physicians
• U.S. should set specific targets for producing
  generalists and specialists and enact policy to
  achieve those targets
• Support care that builds upon the relationship
  between patients and their primary care
  physicians and financially supports the
  patient-centered medical home

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Lesson High performing systems encourage
patients to be prudent purchasers and engage in
healthy behaviors
Belgium France Japan New Zealand Switzerland

• Cost-sharing with co-payment schedules based on
  income can help restrain costs while assuring
  that poorer individuals are still able to access
  services
• Incentives to encourage personal responsibility
  can be effective in influencing healthy
  behaviors, improved health outcomes and
  responsible utilization, without punishing people
  who fail to adopt recommended behaviors or
  lifestyles

Australia Belgium Japan New Zealand Netherlands
Switzerland Taiwan
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Recommendation The U.S. should use financial
incentives for individuals to be prudent
purchasers

• Patients should have ready access to health
  information necessary for informed
  decision-making
• Cost-sharing provisions should be designed to
  encourage patient cost-consciousness without
  deterring patients from receiving needed and
  appropriate services or participating in their
  care

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Lesson High performing systems continuously
measure how well they do and link payment to
performance

• Performance measures, financial incentives linked
  to quality, and active monitoring of performance
  are key elements of health systems that provide
  high quality care

Australia New Zealand United Kingdom
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Lesson The best payment systems recognize the
value of care coordinated by primary care
physicians

• Effective payment systems
• Provide adequate payment for primary care
  services
• Create incentives for quality improvement and
  reporting
• Recognize geographic or local payment differences
• Provide incentives for care coordination

Belgium United Kingdom
Canada Denmark Germany United Kingdom
Denmark Netherlands
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Recommendation U.S. should align payments to
physicians with quality and care coordination

• Provide financial incentives for physicians to
  achieve evidence-based performance standards
• Revise existing volume-based payment systems used
  by Medicare and most private insurers to
• create care coordination payments for physicians
  working with health care teams to provide patient
  care management
• maintain a fee-for-service component for
  separately-identifiable visits
• (modeled on a bundled and hybrid payment model
  used in Denmark and the Netherlands)

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Lesson High performing systems invest in HIT,
have uniform billing, and lower administrative
costs
Germany Canada Taiwan United Kingdom and most
others

• Adoption of a uniform billing system and
  electronic processing of claims improves
  efficiency and reduces administrative expenses
• An inter-operable health information
  infrastructure will enable physicians to obtain
  instantaneous information at the point of medical
  decision-making and enhance electronic
  communications among physicians, hospitals,
  pharmacies, diagnostic testing laboratories, and
  patients

Denmark Taiwan Netherlands
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Lesson High performing systems invest in
research and comparative effectiveness
Canada United Kingdom

• Insufficient investments in research and medical
  technology result in reliance on outdated
  technologies and medical equipment, and delay
  patients access to advances in medical science
• Some countries with national health insurance
  programs have achieved better results (benefit
  and cost) through evidence-based evaluations of
  new drugs and technology

UK Australia
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Recommendation The U.S. should invest in
research to foster continued innovation and
improvements in health care

• Funding should come from both public and private
  sources
• Increase investment in basic health research to
  advance medical knowledge
• Increase funding for health services and
  comparative effectiveness research

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Summary

• The U.S. can learn much by studying what works
  well in other countries and by applying those
  best practices to the U.S.s distinctive
  political system, values and culture
• No single system studied is perfecteach has
  trade-offs. In general
• Single payer systems have lower administrative
  costs, high quality, and satisfaction but cost
  controls may create shortages and delays
• Pluralistic systems can be designed to achieve
  universal coverage with individual freedom to
  purchase additional services, but are less
  equitable and have higher administrative costs
• The evidence shows that either option merits
  consideration by the U.S.

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ConclusionA high performing U.S. health care
system would be one that

• Achieves universal coverage (single payer or
  pluralistic with guaranteed coverage)
• Is built on a foundation of primary care,
  supported by workforce and payment policies
• Provides patients with access to a
  patient-centered medical home
• Pays physicians for care coordination and quality
  instead of volume

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ConclusionA high performing U.S. health care
system would be one that

• Creates positive and non-punitive incentives for
  individuals to be prudent purchasers and engage
  in healthy behavior
• Measures and reports on its own performance
• Has uniform billing and lower administrative
  costs
• Has high levels of public and private investment
  in research (basic, health services, and
  comparative)

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The 47 million (uninsured) question

• What can we do together to assure that the 2008
  elections creates a debate on how to achieve a
  high performing health care system. . .
• . . . So that the next President and Congress
  have a political mandate to learn from other
  health systems and adapt their best practices to
  the United States?