1. THE COMMONWEALTH FUND Transforming The U.S. Health System: What Needs To Be Done & Your Role Stephen C. Schoenbaum, MD, MPH Executive Vice President for Programs www.cmwf.org Mountainside Hospital February 8, 2007

2. THE COMMONWEALTH FUND What We’ll Cover Introduction to The Commonwealth Fund and The Commission on a High Performance Health System Goals for a high performance health system Where we stand now Keys to transforming the health system What you can do

3. THE COMMONWEALTH FUND The Commonwealth Fund Established in 1918, The Commonwealth Fund (www.cmwf.org) is a private national foundation that aims to promote a high performing health care system by supporting independent research on health care issues and making grants to improve health care practice and policy.www.cmwf.org

4. THE COMMONWEALTH FUND 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 and ethnicity, health, or age Chairman: James J. Mongan, M.D. President and CEO Partners HealthCare System, Inc.

5. THE COMMONWEALTH FUND Goals for a High Performance Health System HIGH QUALITY, SAFE, COMPASSIONATE, COORDINATED CARE ACCESS AND EQUITY FOR ALL EFFICIENCY CAPACITY FOR SYSTEM AND WORKFORCE INNOVATION AND IMPROVEMENT LONG, HEALTHY, AND PRODUCTIVE LIVES

6. THE COMMONWEALTH FUND Scores: Dimensions of a High Performance Health System SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

7. THE COMMONWEALTH FUND Mortality Amenable to Health Care Deaths per 100,000 population* Percentiles International Variation, 1998State Variation, 2002 Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care. LONG, HEALTHY & PRODUCTIVE LIVES

8. THE COMMONWEALTH FUND U.S. Adults Receive Half of Recommended Care; Quality Varies Significantly by Medical Condition Source: E. McGlynn et al. 2003. "The Quality of Health Care Delivered to Adults in the United States," The New England Journal of Medicine 248(26): 2635–2645. Percent of recommended care received

9. THE COMMONWEALTH FUND Patients Reporting Any Error by Number of Doctors Seen in Past Two Years Percent 2005 Commonwealth Fund International Health Policy Survey

10. THE COMMONWEALTH FUND Number of States with High Proportion of Uninsured Adults Ages 18–64 Is Growing Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute. Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 ACCESS: UNIVERSAL PARTICIPATION

11. THE COMMONWEALTH FUND Quality and Costs of Care for Medicare Patients Hospitalized for Heart Attacks, Colon Cancer and Hip Fractures, by Hospital Referral Regions, 2000-2002 Median Relative Resource Use = $25,995 * Indexed to risk-adjusted 1 year survival rate (median = 0.70). ** Risk-adjusted spending on hospital and physician services using standardized national prices. Data: E. Fisher and D. Staiger, Dartmouth College analysis of data from a 20% national sample of Medicare beneficiaries. Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 EFFICIENCY

12. THE COMMONWEALTH FUND Best Practice Curve Median Amount Spent per Patient per HRR = $28,694 Greenville, NC Newark, NJ Saginaw, MI Manhattan, NY Orange County, CA East Long Island, NY Ft. Lauderdale, FL Camden, NJ Variation in Annual Total Cost and Quality for Chronic Disease Patients Quality of Care* and Medicare Spending for Beneficiaries with Three Chronic Conditions, by Hospital Referral Region New Brunswick, NJ Hackensack, NJ

13. THE COMMONWEALTH FUND International Comparison of Spending on Health, 1980– 2004 Data: OECD Health Data 2005 and 2006. Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 EFFICIENCY 13

14. THE COMMONWEALTH FUND Percentage of National Health Expenditures Spent on Health Administration and Insurance, 2003 Net costs of health administration and health insurance as percent of national health expenditures a b c * Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 EFFICIENCY

15. THE COMMONWEALTH FUND The Discourse Has Changed FROM: “Americans have the best health care system in the world” –President Bush, State of the Union Speech, 2004 TO: We need to do better –We spend more on health care than any other country –We need more value for what we are spending

16. THE COMMONWEALTH FUND We Know The Problems Now We Need Solutions

17. THE COMMONWEALTH FUND 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 primary and preventive care and is patient-centered 4.Increase transparency and reporting on quality and costs 5.Expand the use of interoperable information technology 6.Reward performance on quality and efficiency 7.Encourage public-private collaboration to achieve simplification, more effective change

18. THE COMMONWEALTH FUND Guarantee Affordable Health Insurance Coverage 1. Guarantee Affordable Health Insurance Coverage

19. THE COMMONWEALTH FUND What Are the Most Important Health Care Issues for Presidential and Congressional Action? Percent listing issue as first or second priority:Total Less than $50,000 $50,000– $74,999 $75,000 or more Ensure that all Americans have adequate, reliable health insurance 52565250 Control the rising cost of medical care37354239 Lower the cost of prescription drugs31 2733 Ensure that Medicare remains financially sound in the longterm 29 3230 Improve the quality of nursing homes and long-term care 14161513 Reform the medical malpractice system14101218 Reduce the complexity of insurance12 10 Source: C. Schoen, S.K. How, I. Weinbaum, J.E. Craig, Jr., and K. Davis, “Public Views on Shaping the Future of the U.S. Health System,” The Commonwealth Fund, August 2006.

20. THE COMMONWEALTH FUND Why Do We Need Universal Coverage? Waste –cost-shifting –ineffective care (poorer adherence) –duplication –back-end vs. front-end care Societal benefit It’s Not Just Altruism

21. THE COMMONWEALTH FUND The Action Now Lies In States Single payer isn’t likely Common elements –Expand public programs (cover more poor people) –Require individual participation –Require employer participation

22. THE COMMONWEALTH FUND Massachusetts Health Plan MassHealth expansion for children up to 300% Federal Poverty Level; adults up to 100% FPL Individual mandate, with affordability provision; subsidies between 100% and 300% of poverty Employer mandatory offer, employee mandatory take-up Employer assessment ($295 if employer doesn’t 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. THE COMMONWEALTH FUND California Governor’s Proposal Individual mandate Premium subsidies for adults below 250% federal poverty level Employer offer health insurance or pay 4% of wages into pool Provider fee assessment (2% of physician revenues to 4% of hospital revenues) Insurance market regulation –Guaranteed issue –Community rating with age bands –85 percent minimum medical loss ratio

24. THE COMMONWEALTH FUND Effective May, 2006: New law in New Jersey allowing persons up to age 30 to be covered under their parents’ insurance

25. THE COMMONWEALTH FUND Implement Major Quality and Safety Improvements 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage

26. Allegheny General Hospital Richard Shannon, MD

27. Highmark “Quality Blue” Year 4 MRSA

28. THE COMMONWEALTH FUND Institute for Healthcare Improvement 100K Lives Campaign: Success Story

29. THE COMMONWEALTH FUND Patient-Centered Hospital Care: Staff Managed Pain, Responded When Needed Help, and Explained Medicines, 2005 Percent of patients reporting “always” * ** ***

30. THE COMMONWEALTH FUND Reid Hospital; Richmond, Indiana 2004 HQA Ave. Reid Hospital Q4 2004 AMI:ACEI when appropriate 75100 CHF: LV assessment 7899 CAP: Pneumo- coccal Vaccine 46100