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Title: Why Not the Best? How States Can Lead Us Toward a High Performance Health System


1
Why Not the Best? How States Can Lead Us Toward
a High Performance Health System
  • Karen Davis
  • President, The Commonwealth Fund
  • National Academy for State Health Policy
  • Annual Policy Conference
  • October 16, 2006

2
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/ethnicity, health, or
    age

Commission Members, including James J. Mongan,
MD, Chairman Alan Weil, JD and others
3
VisionWhat Constitutes a High Performance
Health System?
4
The Commonwealth Fund Commission on a High
Performance Health System
HIGH QUALITY CARE
ACCESS FOR ALL
LONG,HEALTHY, ANDPRODUCTIVELIVES
EFFICIENT CARE
EQUITY
SYSTEM INNOVATION AND IMPROVEMENT
5
Achieving 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

6
State PerformanceWhere We Are Now and
Achievable Benchmarks
7
Mortality Amenable to Health Care
LONG, HEALTHY PRODUCTIVE LIVES
Deaths per 100,000 population
State Variation, 2002
International Variation, 1998
Countries age-standardized death rates, ages
074 includes ischemic heart disease. See
Technical Appendix for list of conditions
considered amenable to health care in the
analysis. Data International estimatesWorld
Health Organization, WHO mortality database
(Nolte and McKee 2003) State estimatesK.
Hempstead, Rutgers University using Nolte and
McKee methodology.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
8
Infant Mortality Rate
LONG, HEALTHY PRODUCTIVE LIVES
Infant deaths per 1,000 live births
International variation, 2002
State variation, 2002
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
9
States 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.
10
Preventive Care Visits for Children, by Top and
Bottom States, Race/Ethnicity, Family Income, and
Insurance
QUALITY THE RIGHT CARE
Percent of children (ages lt18) who 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
11
Immunizations for Young Children, by Top and
Bottom States, Race/Ethnicity, and Family Income
QUALITY THE RIGHT CARE
Percent of children (ages 1935 months) who
received all recommended doses of five key
vaccines
Recommended vaccines include 4 doses of
diphtheria-tetanus-pertussis (DTP), 3 doses of
polio, 1 dose of measles-mumps-rubella, 3doses
of Haemophilus influenzae type B, and 3 doses of
hepatitis B vaccine. PI Pacific Islander AI/AN
American Indian or Alaskan Native. Data
National Immunization Survey (AHRQ 2005a, 2005b).
Data is from 2003.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
12
Pressure 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
13
Percent of Adults Ages 1864 Uninsured by State
ACCESS UNIVERSAL PARTICIPATION
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
14
States with Highest and LowestAdjusted Health
Plan PremiumsEmployee-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. Data is from 2002.
15
EFFICIENCY
Ambulatory Care Sensitive (Potentially
Preventable)Hospital Admissions for Select
Conditions
Adjusted rate per 100,000 population

Combines four diabetes admission measures
uncontrolled, short-term complications, long-term
complications, and lower extremity amputations.
Data National estimatesHealthcare Cost and
Utilization Project, Nationwide Inpatient Sample
State estimatesState Inpatient Databases not
all states participate in HCUP (AHRQ 2005a). Data
is from 2002.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
16
Hospital Admission RatesAmong Nursing Home
Residents, by State
QUALITY COORDINATED CARE
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.
16
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
17
Children 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
18
Diabetes Receipt of All Three Recommended
Services,by Race/Ethnicity, Family Income,
Insurance, and Residence
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). Data is from 2002.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
19
State Health Policies Aimed at Promoting
Excellent Systems (SHAPES)
  • Environmental scan of state-level policies that
    promote or impede high performance
  • Qualitative companion to Commission's
    quantitative National Scorecard
  • Mechanism for identifying innovative states for
    future Commission site visits
  • Four Commission members serve on advisory
    committee
  • Products to date
  • Data information collection plan completed
  • Survey drafted -- will probe broadly the policy
    domains of coverage, quality/efficiency/value,
    and infrastructure supports
  • Data collection to begin September 2006
  • Health policy community notified at Academy
    Health June 25, 2006

Alan Weil, NASHP
Catherine Hess, NASHP
20
Keys to Transforming the U.S. Health Care System
  1. Guarantee affordable health insurance coverage
  2. Implement major quality and safety improvements
  3. Work toward a more organized delivery system that
    emphasizes patient-centered primary and
    preventive care
  4. Increase transparency and reporting on quality
    and costs
  5. Expand the use of interoperable information
    technology
  6. Reward performance for quality and efficiency
  7. Encourage public-private collaboration to achieve
    simplification, more effective change

21
Guarantee Affordable Health Insurance Coverage
1. Guarantee Affordable Health Insurance Coverage
22
Massachusetts 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
  • 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.
23
Retaining 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).
24
Vermont Health Care Affordability Act Enacted
May 2006
  • Coverage expansion
  • Catamount Health Plans
  • Targets those w/o access to work-based coverage
  • Premium subsidies based on sliding scale up to
    300 FPL
  • Comprehensive benefit package including primary,
    chronic, acute care other services
  • No patient cost-sharing for preventive or chronic
    care
  • Builds upon Wagners Chronic Care Model
  • Financing
  • Employer assessment
  • Increase in tobacco taxes
  • Federal matching funds from Medicaid waiver
  • Quality improvement initiatives
  • Public-private collaboration
  • Collection of health care data from all payers
  • Rules to publicly report price quality
    information

25
Illinois 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
  • Federal and state funds
  • Children lt200 of FPL covered by federal funds
  • Children 200 of FPL funded by state savings
    from Medicaid Primary Care Case Management
    Program
  • All-Kids Training Tour
  • Public outreach program to highlight new and
    expanded healthcare programs

26
New 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 NJ residents or FT 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)
27
Implement Major Quality and Safety Improvements
1. Guarantee Affordable Health Insurance Coverage
2. Implement Major Quality and Safety Improvements
28
Rhode IslandFive-Point Strategy
  • Creating affordable 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 -- 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

29
Work 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
30
Helping Patients Become Informed and Active
Partners in Their Care
  • Patient-centered care
  • www.howsyourhealth.org
  • PCDC advanced access collaborative
  • Shared decision-making
  • Resident-centered care in nursing homes
  • Family-centered care in Healthy Steps ABCD

31
Resident-Centered Nursing Home Care for Frail
Elders
  • Green House in Tupelo, Mississippi, featured in
    New York Times and AARP Bulletin Commonwealth
    supported evaluation in progress
  • Ohio project finds high correlation between
    resident and family satisfaction and nursing home
    clinical quality
  • New York state analysis of use of hospitals by
    nursing home residents

32
Utahs 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

33
State Initiatives Investing in Childrens
Preventive Care
MN
VT
WI
RI
MI
NE
OH
NV
DC
CO
VA
MO
TN
OK
AZ
SC
AR
NM
GA
MI
TX
LA
FL
ABCD I States (4)
PHDS SLN States (4)
Improvement Partnership States (5)
ABCD II States (5)
NC Model States (5)
BCAP States (10))
34
Increase 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
35
Wisconsin
  • 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

36
Expand 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
37
Value of Electronic Medical Records and
Information Systems
  • Reduce duplicate tests
  • Reduce hospital admissions by having information
    accessible to ER physicians
  • Improve patient care
  • Decision support for physicians and patients
  • Facilitate referrals, secure transfer of
    responsibility
  • Reduce medical errors
  • Better management of chronic conditions and care
    coordination
  • Registries
  • Performance information
  • Facilitated by interoperability

38
Information ExchangeStates Leading the Way
  • Rhode Island Quality Institute Information
    Exchange
  • Provide access to patient data (as permitted) to
    all providers initially through secure web-based
    portal future integration into EHRs
  • Create the ability to aggregate and utilize data
    for public health purposes (e.g.,
    population-based analysis, biosurveillance)
  • MidSouth e-health Alliance Memphis, TN
  • State-wide data exchange with initial focus on
    EDs
  • Utah Health Information Network
  • Secure exchange of health care data using
    standardized transactions through a single portal
  • 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.
39
Reward 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
40
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 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.
41
New York State Medicaid Pay-for-Performance
  • 1997 NYS began transition to mandatory
    statewide Medicaid managed care. Currently gt 2.5
    million enrollees (including Family Health Plus)
  • 2002 NYS DOH incorporated quality incentive
    into computation of Medicaid managed care
    capitation rates
  • Incentive tied to performance on 10 quality of
    care measures and 5 consumer satisfaction
    measures
  • Initial incentive up to an additional 1 of
    monthly premium as of April 2005, maximum
    incentive increased to 3
  • 2005 incentive payments totaled 40 million
  • Commonwealth Fund supporting Dr. Robert Berenson
    (Urban Institute) to evaluate impact of quality
    incentive program qualitative analysis
    (interviews/site visits of participating plans)
    and quantitative analysis of measures

42
Assisting States in the Design of Medicaid
Pay-for-Performance ProgramsCHCS/Stephen
Somers, Jul 06Jun 08
Overview
  • Develop Pay-for-Performance Purchasing Institute
    Technical Assistance Series for 6 state Medicaid
    teams
  • Two in-person training institutes
  • Follow-up technical assistance
  • Conduct environmental scan on P4P lessons learned
    in the public/private sectors focusing on the
    provider level
  • Draft report expected Sep 2006
  • Synthesis of lessons learned and best practices
  • Draft report expected May 2008

Status
  • 1st training institute scheduled for October
    1213, 2006
  • State Participants Arizona, Connecticut, Idaho,
    Massachusetts, Missouri, Ohio, West Virginia

43
Encourage 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
44
Minnesota 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

45
Washington State Puget Sound Health Alliance
  • Founded in 2004 as independent non-profit
    organization
  • Five-county partnership among employers,
    physicians, hospitals, consumers, health plans
    and others
  • Multi-prong approach to improving care and
    systemness
  • Developing evidence-based guidelines for
    physicians, hospitals and other health care
    professionals
  • Designing tools for consumers and patients to
    support decision making self management of
    chronic conditions
  • Producing regional reports on quality, cost
    value to be made publicly available by end of
    2006
  • Promoting data sharing across health plans
    providers with the goal of a shared data
    repository
  • Building regional infrastructure to support and
    sustain QI, including workforce development
    training

46
West Virginia Small Business PlanLeveraging
Purchasing Power
  • West Virginia (WV) Small Business Plan
  • Enacted March 2004
  • Partnership between WV Public Employees Insurance
    Agency (PEIA) private market insurers
  • Small business insurers pay providers at same
    rates negotiated by PEIA

47
Moving Forward
48
What States Can Do to Promote a High Performance
Health System Strategies to Expand Coverage
  • Expand public programs
  • Provide financial assistance to workers and
    employers to afford coverage
  • Promote partnerships with employers
  • Pool purchasing power and promote new benefit
    designs to make coverage more affordable
  • Mandate that employers offer, and/or individuals
    purchase, coverage subsidize those with low
    incomes
  • Develop reinsurance programs to make coverage
    more affordable in the small group and individual
    markets

49
What 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

50
Continue to Lead the Way to Achieving a High
Performance Health System!
51
Selected 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
  • C. Schoen et al., U.S. Health System
    Performance A National Scorecard, Health
    Affairs Web Exclusive, September 20, 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

52
Thank You!
Stephen C. Schoenbaum, M.D., Executive Vice
President and Executive Director, Commission on a
High Performance Health System
Karen B. Adams, Program Officer, State
Innovations Program
Cathy Schoen, Senior Vice President for Research
and Evaluation
Alyssa L. Holmgren, Research Associate
Jennifer L. Kriss, Program Assistant
Anne Gauthier, Senior Policy Director, Commission
on a High Performance Health System
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