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THE COMMONWEALTH FUND Karen Davis President, The Commonwealth Fund National Association of Community Health Centers Plenary Address March 27, 2006

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Presentation on theme: "THE COMMONWEALTH FUND Karen Davis President, The Commonwealth Fund National Association of Community Health Centers Plenary Address March 27, 2006"— Presentation transcript:

1 THE COMMONWEALTH FUND Karen Davis President, The Commonwealth Fund National Association of Community Health Centers Plenary Address March 27, A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency

2 2 THE COMMONWEALTH FUND 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 3 THE COMMONWEALTH FUND 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 4 THE COMMONWEALTH FUND Community Health Centers Can 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 5 THE COMMONWEALTH FUND Community Health Centers: Key Role in Caring for Most Vulnerable

6 6 THE COMMONWEALTH FUND Health Center Patients Are Predominantly Low-Income, and Most are Uninsured or Have Medicaid Source: Bureau of Primary Health Care, 2003 Uniform Data System Uninsured 39% Medicaid/ SCHIP 36% Medicare 7% Other public 3% Private 15% 100% poverty and below 69% 101–150% poverty 14% 151–200% poverty 6% Over 200% poverty 10% Patients by Poverty LevelPatients by Insurance Status

7 7 THE COMMONWEALTH FUND Racial and Ethnic Minorities Make Up Two-Thirds of all Health Center Patients Source: Bureau of Primary Health Care, 2002 Uniform Data System

8 8 THE COMMONWEALTH FUND Nearly One-Third of Health Center Patients Prefer Languages Other than English Source: Uniform Data System, BPHC, HRSA, DHHS. Percent of users preferring languages other than English

9 9 THE COMMONWEALTH FUND Proportion of Vulnerable Populations at Health Centers and in the U.S. * Most recent year available. # For a family of three, $15,260 annual income in 2003 and %15,670 for in Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC Report, August Health centers, 2004 U.S. Population, 2003* Income Less than 100% poverty # 71%13% Less than 200% poverty 9131 Insurance status Uninsured 4016 Medicaid 3612 Minority 6432

10 10 THE COMMONWEALTH FUND Growth in Health Center Patients by Insurance Status, Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC Report, August In millions

11 11 THE COMMONWEALTH FUND Community Health Centers: A Leader in High Performance Care

12 12 THE COMMONWEALTH FUND 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 Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care. Medical Care Research and Review 58(2):

13 13 THE COMMONWEALTH FUND 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):

14 14 THE COMMONWEALTH FUND Pap Tests by Race: Women 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 15 THE COMMONWEALTH FUND Self-Reported Quality Assessment of Care Received at Health Centers Percent Source: PEERS Report, NACHC analysis of PEERS,

16 16 THE COMMONWEALTH FUND Wait Times at Health Centers, 1993–2001 Source: PEERS Report, NACHC analysis of PEERS, Percent of health center patients

17 17 THE COMMONWEALTH FUND Community Health Centers: Assuming a Leadership Role in A High Performance Health System

18 18 THE COMMONWEALTH FUND 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 19 THE COMMONWEALTH FUND Attributes of Patient-Centered Primary Care Superb access to care –Quick appointments, short waiting times, accessible off-hours coverage, 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 20 THE COMMONWEALTH FUND Insurance Status and Continuity of Care with a Regular Doctor 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 Same doctor for more than 5 years 18% No regular doctor 54% Same doctor for fewer than 5 years 28% No regular doctor 19% Same doctor for fewer than 5 years 47% Same doctor for more than 5 years 34% Uninsured adults (full or part year)Insured adults

21 21 THE COMMONWEALTH FUND People in Community Health Centers Who Have a Usual Source of Care, 2002 Source: AHRQ, Focus on Federally Supported Health Centers, National Healthcare Disparities Report, Percent

22 22 THE COMMONWEALTH FUND Minorities Without a Regular Doctor Are More Likely to Use Emergency Room for Care Source: K.S. Collins et al., Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans, The Commonwealth Fund, March 2002 Percent reporting emergency room or no regular place of care

23 23 THE COMMONWEALTH FUND 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 Percent AUS CAN NZ UK US Same day appointment Went to ER for condition that could have been treated by regular doctor if available AUS CAN NZ UK US Source: 2004 Commonwealth Fund International Health Policy Survey Access to Doctor When Sick or Needed Medical Attention

24 24 THE COMMONWEALTH FUND 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 LAB FRONT DESK FRONT DESK CLERK EXIT CASHIER WAITING ROOM EXAM ROOM EXIT FRONT DESK After Redesign 50 Minutes, 4 Steps 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 25 THE COMMONWEALTH FUND The PCDC Track Record ProgramTeamsOutcomes Redesign (7 Collabs) 77Cycle time: 109 to 53 minutes Waiting around time: 106 to 0- minimum. Visits/hour/provider: 2.9 to 3.2 Advanced Access (5 Collabs) 24Days for next available appt: 21 to range of 0-5 No show rate: 50% to 38% Rev Max (3 Collabs) 231 st 5 teams: $512,000 2 nd 4 teams: $2.4M (incl. 1 large hospital) 3 rd 14 teams: $2.2 (all CHCs) Marketing (3 Collabs) 1314% increase in patients Total137

26 26 THE COMMONWEALTH FUND 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 27 THE COMMONWEALTH FUND Percent Patient Access to Personal Health Records Source: The Commonwealth Fund 2004 International Health Policy Survey

28 28 THE COMMONWEALTH FUND Electronic Access to Patient Test Results & Medical Records (EMRs), and Electronic Ordering, by Practice Size Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Percent who currently routinely/occasionally use the following * Electronic ordering of tests, procedures, or drugs. *

29 29 THE COMMONWEALTH FUND E.Wagner, MD

30 30 THE COMMONWEALTH FUND 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 31 THE COMMONWEALTH FUND New York City Health and Hospitals Corporation: Diabetes Outcomes: HBA1c, Blood Pressure Average A1C<7 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 32 THE COMMONWEALTH FUND Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. Percent indicating involvement in redesign and collaborative efforts Physicians Participation in Redesign and Collaborative Activities, by Practice Size Redesign EffortsCollaborative Efforts* Total10–49 Physicians1 Physician50+ Physicians2–9 Physicians * Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years.

33 33 THE COMMONWEALTH FUND 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 34 THE COMMONWEALTH FUND Tax Revenues at Lowest Percent of GDP in 40 Years Note: Actual 1962–2004; Projected 2005–2015. Source: Congressional Budget Office, The Budget and Economic Outlook: Fiscal Years 2006 to 2015, January Percent of GDP ActualProjected Average Outlays, Average Revenues,

35 35 THE COMMONWEALTH FUND Average Annual Medicaid Spending Growth Per Enrollee Lower Than Private Health Spending, 2000–2003 Percent average annual growth Source: J. Holahan and A. Ghosh, Understanding the Recent Growth in Medicaid Spending, 2000– 2003, 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 36 THE COMMONWEALTH FUND Higher Deductibles Associated with Greater Access Problems Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (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, Percent of adults ages 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

37 37 THE COMMONWEALTH FUND Percent of Adults Ages 18–64 Uninsured by State WA OR ID MT ND WY NV CA UT AZNM KS NE MN MO WI TX IA IL IN AR LA AL SC TN NC KY FL VA OH MI WV PA NY AK MD ME VT NH MA RI CT DE DC HI CO GAMS OK NJ SD WA OR ID MT ND WY NV CA UT AZNM KS NE MN MO WI TX IA IL IN AR LA AL SC TN NC KY FL VA OH MI WV PA NY AK ME DE DC HI CO GAMS OK NJ SD 19%–23.9% Less than 14% 14%–18.9% 24% or more 1999– –2004 Source: Two-year averages 1999–2000 and 2003–2004 from the Census Bureaus March 2000, 2001 and 2004, 2005 Current Population Surveys. Estimates by the Employee Benefit Research Institute. MA RI CT VT NH MD

38 38 THE COMMONWEALTH FUND Without Insurance it Is Difficult to Obtain Specialized Care 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): 188–94. Can provide all necessary services using health center's resources Can obtain non- emergency admissions Can obtain specialty referrals

39 39 THE COMMONWEALTH FUND Proportion of U.S. Physicians Providing Charity Care Is Declining Percent * Change from is statistically significant at p<.05 # Change from is statistically significant at p<.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 # #*#*

40 40 THE COMMONWEALTH FUND Retaining and Expanding Employer Participation: Maines Dirigo Health 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 * After discount and employer payment (for illustrative purposes only). Annual expenditures on deductible and premium $550 $0 $1,100 $1,638 $2,188 $2,738

41 41 THE COMMONWEALTH FUND 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, P&G, 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

42 42 THE COMMONWEALTH FUND Building Quality Into RIte Care Higher 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 Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, Cumulative Health Insurance Rate Trend Comparison RI Commercial Trend RIte Care Trend Percent

43 43 THE COMMONWEALTH FUND 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 44 THE COMMONWEALTH FUND 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:


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