Karen Davis

1
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
• kd_at_cmwf.org
• www.cmwf.org

2
Need for Better Access, Higher Quality, and
Greater Efficiency

• 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

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

4
Community Health CentersCan 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

5
Community Health CentersKey Role in Caring for
Most Vulnerable
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 10
Private 15
Uninsured 39
Other public 3
151200 poverty 6
Medicare 7
101150 poverty 14
100 poverty and below 69
Medicaid/ SCHIP 36
Source Bureau of Primary Health Care, 2003
Uniform Data System
7
Racial and Ethnic Minorities Make Up Two-Thirds
of all Health Center Patients
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
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
Income
Less than 100 poverty 71 13
Less than 200 poverty 91 31
Insurance status
Uninsured 40 16
Medicaid 36 12
Minority 64 32
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.
10
Growth in Health Center Patients by Insurance
Status, 1999-2004
In millions
Source National Association of Community Health
Centers, Safety Net on the Edge, NACHC Report,
August 2005.
11
Community Health CentersA Leader in High
Performance Care
12
Increased Access of Uninsured to Care

• Health Center Patients
• 25 delayed care due to costs
• 16 went without needed care
• 12 could not fill Rx

• Non-Health Center Patients
• 55 delayed care due to costs
• 30 went without needed care
• 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.
13
Ambulatory Care Sensitive Events by Regular
Source of Care
Number of ACS events per 100 persons
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.
14
Pap Tests by RaceWomen Served by Community
Health Centers Compared to National Sample
Source Dan Hawkins, Improving Minority Health
and Reducing Disparities through the
Health Disparities Collaboratives of Americas
Community Health Centers, Presentation to NAPH
(June 24, 2005) Santa Fe, NM.
15
Self-Reported Quality Assessment of Care Received
at Health Centers
Percent
Source PEERS Report, NACHC analysis of PEERS,
1993-2001
16
Wait Times at Health Centers, 19932001
Percent of health center patients
Source PEERS Report, NACHC analysis of PEERS,
1993-2001
17
Community Health CentersAssuming a Leadership
Role in A High Performance Health System
18
Actions Community Health Centers Can Take to
Promote High Performance

• 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

19
Attributes of Patient-Centered Primary Care

• 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 and other clinicians
  providing care

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
Same doctor for fewer than 5 years 47
Uninsured adults (full or part year)
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.
21
People in Community Health Centers Who Have a
Usual Source of Care, 2002
Percent
Source AHRQ, Focus on Federally Supported
Health Centers, National Healthcare Disparities
Report, 2004. http//www.qualitytools.ahrq.gov/dis
paritiesReport/browse/browse.aspx?id4981
22
Minorities Without a Regular DoctorAre More
Likely to Use Emergency Room for Care
Percent reporting emergency room or no regular
place of care
Source K.S. Collins et al., Diverse
Communities, Common Concerns Assessing Health
Care Quality for Minority Americans, The
Commonwealth Fund, March 2002
23
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
Access to Doctor When Sick or Needed Medical
Attention
Percent
AUS CAN NZ UK US
AUS CAN NZ UK US
Went to ER for condition that could have been
treated by regular doctor if available
Same day appointment
Source 2004 Commonwealth Fund International
Health Policy Survey
24
Primary Care Development Corporation Primary Care
Clinic Redesign Collaborative Before
Redesign 148 Minutes, 11 Steps
FRONT DESK
CASHIER
WAITING ROOM
NURSING STATION
WAITING ROOM
EXAM ROOM
NURSING STATION
BATHROOM
FRONT DESK CLERK
FRONT DESK
LAB
EXIT
After Redesign 50 Minutes, 4 Steps
WAITING ROOM
EXAM ROOM
CASHIER
EXIT
FRONT DESK
Source Pamela Gordon, M.A., and Matthew Chin,
M.P.A., Achieving a New Standard in Primary Care
for Low-Income 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 0-minimum. 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
26
Center for Shared Decision-Making
Dartmouth-Hitchcock Medical Center

• 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
27
Patient Access to Personal Health Records
Percent
88
82
80
80
70
Source The Commonwealth Fund 2004 International
Health Policy Survey.
28
Electronic Access to Patient Test Results
Medical Records (EMRs), and Electronic Ordering,
by Practice Size
Percent who currently routinely/occasionally
use the following

Electronic ordering of tests, procedures, or
drugs.
Source The Commonwealth Fund National Survey of
Physicians and Quality of Care.
29
E.Wagner, MD
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

31
New York City Health and Hospitals
CorporationDiabetes Outcomes HBA1c, Blood
Pressure

• Average A1Clt7 increased from 30 to 42
• 31 with BP 130/80 at baseline, increased to 57

Source Karen Scott-Collins, MD, MPH, Deputy
Chief Medical Officer, Health Care Quality and
Clinical Services, New York City Health and
Hospitals Corporation
32
Physicians Participation in Redesign and
Collaborative Activities, by Practice Size
Percent indicating involvement in redesign and
collaborative efforts
Total
1049 Physicians
1 Physician
50 Physicians
29 Physicians
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.
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 nations health
  care problems not being considered

34
Tax Revenues at Lowest Percent of GDP in 40 Years
Percent of GDP
Actual
Projected
Average Outlays, 1962-2004
Average Revenues, 1962-2004
Note Actual 19622004 Projected
20052015. Source Congressional Budget Office,
The Budget and Economic Outlook Fiscal Years
2006 to 2015, January 2005.
35
Average Annual Medicaid Spending Growth Per
Enrollee Lower Than Private Health Spending,
20002003
Percent average annual growth
Source J. Holahan and A. Ghosh, Understanding
the Recent Growth in Medicaid Spending,
20002003, 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
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

• Administration policy provides for
• Tax incentives for the purchase of high
  deductible health plans
• Tax credits for low-income 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 low-income and chronically
  ill

Note Comprehensive plan w/ no deductible or
lt1000 (ind), lt2000 (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.
37
Percent of Adults Ages 1864 Uninsuredby State
19992000
20032004
NH
ME
WA
NH
VT
ME
WA
VT
ND
MT
ND
MT
MN
MN
OR
NY
MA
WI
OR
MA
NY
ID
SD
RI
WI
MI
ID
SD
RI
WY
MI
CT
PA
WY
NJ
IA
CT
PA
NJ
NE
OH
IA
DE
IN
NE
OH
NV
DE
IN
IL
MD
NV
WV
UT
VA
IL
MD
DC
CO
WV
UT
VA
KS
CA
MO
KY
DC
CO
KS
CA
MO
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
HI
HI
24 or more
1923.9
1418.9
Less than 14
Source Two-year averages 19992000 and 20032004
from the Census Bureaus March 2000, 2001
and 2004, 2005 Current Population Surveys.
Estimates by the Employee Benefit Research
Institute.
38
Without Insurance it Is Difficult to Obtain
Specialized Care
Can provide all necessary services using health
center's resources
Can obtain non-emergency admissions
Can obtain specialty referrals
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) 18894.
39
Proportion of U.S. Physicians Providing Charity
Care Is Declining
Percent


Change from 2000-01 is statistically
significant at plt.05 Change from 1996-977 is
statistically significant at plt.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.
40
Retaining and Expanding Employer Participation
Maines Dirigo Health
Annual expenditures on deductible and premium

• 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 11,000 as of 10/20/05

2,738
2,188
1,638
1,100
550
0
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, PG, 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/
42
Building 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 Rate 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.
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

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