Why Not the Best? A High Performance Health System in Hawaii Hawaii Uninsured Project Fall Forum October 23, 2006 Anne Gauthier Senior Policy Director The Commonwealth Fund

Presentation Overview The Commission on a High Performance Health System The National Landscape: How are States Performing Compared to Achievable Benchmarks State Efforts to Improve Performance Legislative Proposals Moving Forward

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 The Commission is made up of 19 Commission members who come with divers practical and policy expertise in health care delivery, financing, and access and quality improvement.

Major Commission Products Framework Statement (August 2006) –Provides sense of urgency to transform U.S. health care –Defines “systemness” and stresses need to achieve it –Depicts major sources of current system failures –Delineates roles for public and private sectors Scorecard Report (September 2006) –Compares U.S. national average with the best achieved benchmarks across arenas of quality, access, efficiency, and equity –Provides a mechanism for monitoring change over time –Provides a yardstick against which to assess the effects of existing or proposed policies to improve performance The framework and scorecard reports are aligned in using the same dimensions of high performance

Commission Conception of High Performing Health System QUALITY Getting the right care Coordinated care Safe care Patient-centered care ACCESS Universal participation Affordable Equitable EFFICIENCY SYSTEM CAPACITY TO IMPROVE LONG, HEALTHY, AND PRODUCTIVE LIVES

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

The National Landscape: How are States Performing Compared to Achievable Benchmarks? C A F D

The U.S. falls far short on each of the core goals for health system performance relative to benchmarks –The US average ratio score is 66 across health outcomes, quality, access, equity, and efficiency –There are wide gaps across key indicators on benchmarks largely drawn from achieved rates The consequence is needlessly lost lives, wasted health care expenditures, and lower economic productivity –$50 to $100 Billion annual savings and 100,000 to 150,000 lives –$130 billion in potential productivity gains from insuring the uninsured (IOM estimate) Given that the US spends more than any other country, we should expect to lead on access, quality and efficiency –Benchmarks provide targets for improvement With cost and coverage vital signs moving in the wrong direction, moving to a high performance system is of great urgency to secure a healthy nation Scorecard on US Health System

Mortality Amenable to Health Care Deaths per 100,000 population* Percentiles International Variation, 1998State Variation, 2002 * Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease DATA: International: WHO mortality database from Nolte and McKee 2003; U.S state estimates: K. Hempstead, Rutgers University using Nolte/ McKee methodology. Methods in technical appendix to Scorecard Chartpack. SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 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

Infant Mortality Rate, 2002 * Data: International estimates—OECD Health Data 2005; State estimates—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2005a). Infant deaths per 1,000 live births International variationState variation LONG, HEALTHY & PRODUCTIVE LIVES Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

States Vary In Quality of Care First Third Fourth Source: S.F. Jencks, E.D. Huff, and T. Cuerdon, “Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998–1999 to 2000–2001,” Journal of the American Medical Association 289, no. 3 (Jan. 15, 2003): 305–312. Second Quartile Rank Note: State ranking based on 22 Medicare performance measures. 2000–2001

Percent of children (ages <18) received BOTH a medical and dental preventive care visit in past year Preventive Care Visits for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003 Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 QUALITY: THE RIGHT CARE

Nursing Homes: Hospital Admission and Readmission Rates Among Nursing Home Residents, by State, 2000 Percent Hospitalization rates Re-hospitalization rate (within 3 months of nursing home admission ) Percent 13 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 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 QUALITY: COORDINATED CARE

High-risk residents Pressure Sores Among High-Risk and Short-Stay Residents in Nursing Facilities Percent of nursing home residents with pressure sores Data: Nursing Home Minimum Data Set (AHRQ 2005a). Short-stay residents High-risk residents Short- stay residents White13%21% Black1726 Hispanic1525 Asian1222 AI/AN1723 State distribution, 2004By race/ethnicity, 2003 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 QUALITY: SAFE CARE

Percent of Adults Ages 18–64 Uninsured by State 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. 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%–22.9% Less than 14% 14%–18.9% 23% or more 1999– –2005 MA RI CT VT NH MD NH Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 ACCESS: UNIVERSAL PARTICIPATION

States with Highest and Lowest Adjusted Health Plan Premiums, 2002 States with Highest and Lowest Adjusted Health Plan Premiums, 2002 Employee-only adjusted premiums 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 (3):832–43. Dollars

Medicare Hospital 30-Day Readmission Rates, by Regions, 2003 Rate of hospital readmission within 30 days Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2003 Medicare Standard Analytical Files 5% Inpatient Data SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 Percentiles EFFICIENCY

* 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 child’s specialty care visits. Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at Children with a Medical Home, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance Percent of children who have a personal doctor or nurse and receive care that is accessible, comprehensive, culturally sensitive, and coordinated* Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 QUALITY: COORDINATED CARE

Receipt of All Three Recommended Services for Diabetics, by Race/Ethnicity, Family Income, Insurance, and Residence, 2002 Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year * Insurance for people ages 18–64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants. Data: Medical Expenditure Panel Survey (AHRQ 2005a). * ** Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 EQUITY: THE RIGHT CARE

What are States Doing to Transform Health System Performance? ? C A F D

Keys to Transforming the U.S. Health Care System 1.Guarantee affordable health care 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

State Efforts to Guarantee Affordable Health Insurance Coverage 1. Guarantee Affordable Health Insurance Coverage

Hawaii Employer Mandate Prepaid Health Care Act of 1974 requires all private-sector employers to provide health insurance to full-time employees Only state to implement an employer mandate

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 Employers must offer Section 125 Flex Accounts 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.

Massachusetts Strategies for Coverage: Everyone “does their part” Subsidized insurance The Connector Uncompensated Care pool reform Government Individuals Employers Health Care System Individual Mandate Fair Share Assessment “Free Rider” provisions Mandatory “cafeteria plans” Meet quality and performance standards New levels of “transparency” Adjust to payment changes Expanded Coverage Source: Lischko, Amy. October 16, “Massachusetts Health Reform.” NASHP 19 th Annual State Health Policy Conference, Pittsburgh, PA.

Retaining and Expanding Employer Participation: Maine’s 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 14,700 as of 4/30/06 * 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

Vermont Health Care Affordability Act Enacted May 2006 Coverage expansion –Catamount Health Plans Targets individuals w/o access to work-based coverage Premium subsidies based on sliding scale up to 300% FPL Comprehensive benefit package including primary care, chronic care, acute care & other services No patient cost-sharing for preventive or chronic care services Builds upon Wagner’s Chronic Care Model Financing –Employer assessment –Increase in tobacco taxes –Federal matching funds from Medicaid waiver

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 Funded by federal and state funds –Children <200% of the federal poverty level funded by federal funds –Children 200%+ of the federal poverty level funded by state savings from the Medicaid Primary Care Case Management Program All-Kids Training Tour –Public outreach program to highlight new and expanded healthcare programs

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 either NJ residents or full-time students –Premium capped at 102% of amount paid for dependent’s coverage prior to aging out 200,000 young adults expected to receive coverage under the law 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 (Analysis of the March 2001–2005 Current Population Surveys) Millions uninsured, adults ages 19–29

Implement Major Quality and Safety Improvements 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage

Puget Sound Health Alliance Regional partnership involving employers, physicians, hospitals, patients, health plans Working to promote evidence-based medicine throughout King County, Washington Participants agree to use evidence to identify and measure quality health care, then produce publicly-available comparison reports designed to help improve health care decision-making

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

Utah’s Primary Care Network Section 1115 Medicaid Waiver Targets uninsured adults (19–54) 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

Increase Transparency and Reporting on Quality and Costs 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage

Wisconsin Wisconsin Collaborative for Healthcare Quality –Voluntary consortium formed in 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

Expand the Use of Interoperable Information Technology 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage

Information Exchange: States Leading the Way 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 , January 2006.

Reward Performance for Quality and Efficiency 6. Reward Performance for Quality and Efficiency 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage 5. Expand the Use of Interoperable Information Technology

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 Cost Trend Comparison RI Commercial Trend RIte Care Trend Percent

Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage 6. Reward Performance for Quality and Efficiency 5. Expand the Use of Interoperable Information Technology

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

Expanding Coverage is Only One Piece of the Puzzle 7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage 6. Reward Performance for Quality and Efficiency 5. Expand the Use of Interoperable Information Technology

Several States Attempting Comprehensive Health Reform Maine, Maine and Vermont have quality initiatives built into coverage expansions Maine –Created Maine Quality Forum to advocate for high quality health care and help each Maine citizen make informed health care choices. Massachusetts –Cost and Quality Council formed Vermont –Quality improvement initiatives Public-private collaboration Collection of health care data from all payers Provides rules to publicly report price & quality information

Rhode Island: Five-Point Strategy 5 point strategy –Creating affordable health plans for small businesses & individuals –Increasing wellness programs –Investing in health care technology –Developing centers of excellence –Leveraging the state’s purchasing power RI Quality Institute –Non-profit coalition including 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

National Legislative Proposals to Facilitate State Innovations

H.R. 5684: Health Partnership Through Creative Federalism Act Rep. Tammy Baldwin (D-WI) Rep. Tom Price (R-GA) Real cooperation from across the aisle – proposed by Baldwin and Price with the support of both the Heritage Foundation and the Brookings Institute; National Governor’s Association also had role in drafting the bill Requests that states submit proposals for state health care coverage expansion and improvements in quality, efficiency, cost-effectiveness, and the appropriate use of health information technology State proposals defined as statewide, multi-state or limited to certain regions Establishes a Commission to: – –Request and review proposals and submit a list it recommends for approval to Congress – –Report to the public concerning progress made by states – –Make recommendations for minimizing negative effects of state programs on national employer, provider organizations, insurer

S. 2772: Health Partnership Act Senator George Voinovich (D-WI) Provides states with grants to carry out innovative state health programs, with priority given to programs most likely to expand coverage and improve access Establishes a Commission to: –provide states with reform options for state health care expansion and improvement programs –establish minimum performance measures and goals with respect to coverage, quality, and cost of state programs –review state applications and determine whether to submit a state proposal to Congress Senator Jeff Bingaman (D-NM)

Moving Forward States Can Lead the Way

What States Can Do to Promote a High Performance Health System: Strategies to Expand Coverage Design shared responsibility strategy to include state, employers and individuals Expand public programs Provide financial assistance to low income workers and employers to afford coverage Require employers to offer Section 125 benefit plans Mandate individuals to purchase coverage Require employers to offer and employees to take up insurance Require insurers to raise age limit for dependents Pool purchasing power and promote new benefit designs to make coverage more affordable Develop reinsurance programs to make coverage more affordable in the small group and individual markets

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

Challenge for Hawaii: Continue the commitment to universal coverage AND choose another dimension on which to lead!

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 The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 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 All publications are available at

Visit the Fund at: Acknowledgements Stephen C. Schoenbaum Executive Vice President for Programs Karen Davis President Ilana Weinbaum Program Associate Sabrina How Research Associate Cathy Schoen Senior Vice President for Research and Evaluation Alyssa Holmgren Research Associate