THE COMMONWEALTH

FUND

Karen DavisPresident, The Commonwealth Fund

National Association of Community Health CentersPlenary AddressMarch 27, 2006kd@cmwf.orgwww.cmwf.org

A Need to Transform the U.S. Health A Need to Transform the U.S. Health Care System: Improving Access, Care System: Improving Access,

Quality, and EfficiencyQuality, and Efficiency

2

THE COMMONWEALTH

FUND

Need for Better Access, Higher Quality, and Need for Better Access, Higher Quality, and Greater EfficiencyGreater 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

THE COMMONWEALTH

FUND

Ten Keys to Transforming the U.S. Health Ten Keys to Transforming the U.S. Health Care SystemCare System

1. Agree on shared values and goals2. Organize care and information around the

patient3. Expand the use of information technology4. Enhance the quality and value of care5. Reward performance6. Simplify and standardize7. Expand health insurance and make coverage

automatic8. Guarantee affordability9. Share responsibility for health care financing10. Encourage collaboration

4

THE COMMONWEALTH

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Community Health CentersCommunity Health CentersCan Lead the WayCan 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

THE COMMONWEALTH

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Community Health Centers:Community Health Centers:Key Role in Caring for Most VulnerableKey Role in Caring for Most Vulnerable

6

THE COMMONWEALTH

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Health Center Patients Are Predominantly Low-Health Center Patients Are Predominantly Low-Income, and Most are Uninsured or Have Income, and Most are Uninsured or Have

MedicaidMedicaid

Source: Bureau of Primary Health Care, 2003 Uniform Data System

Uninsured39%

Medicaid/ SCHIP36%

Medicare7%%

Other public

3%

Private15%

100% poverty

and below69%

101–150% poverty

14%

151–200% poverty

6%

Over 200% poverty

10%

Patients by Poverty Level Patients by Insurance Status

7

THE COMMONWEALTH

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Racial and Ethnic Minorities Make Up Racial and Ethnic Minorities Make Up Two-Thirds of all Health Center PatientsTwo-Thirds of all Health Center Patients

A s ian/

Pac ific

Is lander

3%

White

36%

Hispanic /

Latino

35%

A fric an

A meric an

24%

A meric an Indian/

A laska Native

1%

Source: Bureau of Primary Health Care, 2002 Uniform Data System

8

THE COMMONWEALTH

FUND

Nearly One-Third of Health Center Patients Prefer Nearly One-Third of Health Center Patients Prefer Languages Other than EnglishLanguages Other than English

18% 19%23%

27% 28% 29% 30%

0%

10%

20%

30%

40%

50%

1997 1998 1999 2000 2001 2002 2003

Source: 1997-2002 Uniform Data System, BPHC, HRSA, DHHS.

Percent of users preferring languages other than English

9

THE COMMONWEALTH

FUND

Proportion of Vulnerable Populations at Proportion of Vulnerable Populations at Health Centers and in the U.S.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 2004.Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC Report, August 2005.

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

10

THE COMMONWEALTH

FUND

Growth in Health Center Patients by Growth in Health Center Patients by Insurance Status, 1999-2004Insurance Status, 1999-2004

Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC Report, August 2005.

5.34.9

4.44.03.9

3.74.7

4.44.0

3.63.2

2.91.91.81.71.61.51.4

1.00.90.80.70.70.7

0.30.40.40.30.3 0.30

1

2

3

4

5

6

1999 2000 2001 2002 2003 2004

U ninsured

Medic aid

P rivate

Medic are

Other public

In millions

11

THE COMMONWEALTH

FUND

Community Health Centers:Community Health Centers:A Leader in High Performance CareA Leader in High Performance Care

12

THE COMMONWEALTH

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Increased Access of Uninsured to CareIncreased 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

THE COMMONWEALTH

FUND

Ambulatory Care Sensitive Events by Regular Ambulatory Care Sensitive Events by Regular Source of CareSource 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.

6

26

8

38

0

25

50

75

ACS admiss ions ACS emergenc y vis its

Health c enters Other providers

14

THE COMMONWEALTH

FUND

Pap Tests by Race:Pap Tests by Race:Women Served by Community Health Women Served by Community Health Centers Compared to National SampleCenters Compared to National Sample

66

82

73

80

75

89

94

85

86

89

0 20 40 60 80 100

Other

B lac k Non-H ispanic

White Non-H ispanic

H ispanic

A ll Women

CHCNHIS Comparison Group

Source: Dan Hawkins, “Improving Minority Health and Reducing Disparities through the Health Disparities Collaboratives of America’s Community Health Centers,” Presentation to NAPH (June 24, 2005) Santa Fe, NM.

15

THE COMMONWEALTH

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Self-Reported Quality Assessment of Care Self-Reported Quality Assessment of Care Received at Health CentersReceived at Health Centers

Percent

Source: PEERS Report, NACHC analysis of PEERS, 1993-2001

41

55

40

63

36

1 10

25

50

75

Very

satisfied

Satisfied Dissatisfied Very

dissatisfied

1993 2001

16

THE COMMONWEALTH

FUND

Wait Times at Health Centers, 1993–2001Wait Times at Health Centers, 1993–2001

Source: PEERS Report, NACHC analysis of PEERS, 1993-2001

0

10

20

30

40

50

60

Under 15

minutes

15-30

minutes

31-59

minutes

1-3 hours 3+ hours

1993 2001

Percent of health center patients

17

THE COMMONWEALTH

FUND

Community Health Centers:Community Health Centers:Assuming a Leadership Role in A High Assuming a Leadership Role in A High

Performance Health SystemPerformance Health System

18

THE COMMONWEALTH

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Actions Community Health Centers Can Take to Actions Community Health Centers Can Take to Promote High PerformancePromote 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

THE COMMONWEALTH

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Attributes of Patient-Centered Primary CareAttributes 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

THE COMMONWEALTH

FUND

Insurance Status and Insurance Status and Continuity of Care with a Regular DoctorContinuity 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 2002.

Same doctor for more than 5 years

18%

No regular doctor54%

Same doctor for fewer than 5 years

28%

No regular doctor19%

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

THE COMMONWEALTH

FUND

People in Community Health Centers Who People in Community Health Centers Who Have a Usual Source of Care, 2002Have a Usual Source of Care, 2002

Source: AHRQ, “Focus on Federally Supported Health Centers,” National Healthcare Disparities Report, 2004. http://www.qualitytools.ahrq.gov/disparitiesReport/browse/browse.aspx?id=4981

98 98 98

0

25

50

75

100

Non-hispanic w hite A fric an A meric an Hispanic

Percent

22

THE COMMONWEALTH

FUND

Minorities Without a Regular DoctorMinorities Without a Regular DoctorAre More Likely to Use Emergency Room for Are More Likely to Use Emergency Room for

CareCare

16%

27%24%

14%

4%7% 7%

4%

0%

15%

30%

White A fric an

Americ an

Hispanic As ian

Americ an

No Regular Doc tor Regular Doc tor

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

THE COMMONWEALTH

FUND

In U.S., Canada Adults Less Likely to Be Able to See In U.S., Canada Adults Less Likely to Be Able to See Physician Same Day and More Likely to Substitute ER Physician Same Day and More Likely to Substitute ER

for Regular Physician Carefor Regular Physician Care

54

918

60

7

41

6

33

16

27

0

25

50

75Percent

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

THE COMMONWEALTH

FUND

Primary Care Development CorporationPrimary Care Development CorporationPrimary Care Clinic Redesign Collaborative: Primary Care Clinic Redesign Collaborative:

Before RedesignBefore Redesign148 Minutes, 11 Steps148 Minutes, 11 Steps

FRONTDESK

CASHIER WAITINGROOM

NURSINGSTATION

WAITINGROOM

EXAM ROOMNURSINGSTATION

BATHROOM

LABFRONTDESK

FRONT DESK

CLERKEXIT

CASHIERWAITING

ROOMEXAMROOM

EXITFRONTDESK

After RedesignAfter Redesign50 Minutes, 4 Steps50 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

THE COMMONWEALTH

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The PCDC Track RecordThe 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

THE COMMONWEALTH

FUND

Center for Shared Decision-MakingCenter for Shared Decision-Making Dartmouth-Hitchcock Medical Center 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

THE COMMONWEALTH

FUND

3445

28

5140

40 4835

42

37

0

25

50

75

100

A US CA N NZ UK US

Do not have ac c ess to ow n medic al rec ords but w ould like to

H ave ac c ess to ow n medic al rec ordsPercent

Patient Access to Personal Health RecordsPatient Access to Personal Health Records

Source: The Commonwealth Fund 2004 International Health Policy Survey.

80 82 8070

88

28

THE COMMONWEALTH

FUND

1413

36

61

23 25

66

35 3746

57

87

0

25

50

75

100

Elec tronic ac c ess to

tes t results

E lec tronic medic al

rec ords

Elec tronic ordering

1 Phys ic ian 2–9 Phys ic ians 10–49 Phys ic ians 50+ Phys ic ians

Electronic Access to Patient Test Results & Electronic Access to Patient Test Results & Medical Records (EMRs), and Electronic Medical Records (EMRs), and Electronic

Ordering, by Practice SizeOrdering, 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

THE COMMONWEALTH

FUND

E.Wagner, MD

30

THE COMMONWEALTH

FUND

Health Disparities CollaborativesHealth 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

THE COMMONWEALTH

FUND

New York City Health and Hospitals Corporation:New York City Health and Hospitals Corporation:Diabetes Outcomes: HBA1c, Blood PressureDiabetes Outcomes: HBA1c, Blood Pressure

• Average A1C<7 increased from 30% to 42%

• 31% with BP 130/80 at baseline, increased to 57%

Mean A1C <7

0102030405060

Perc

ent

Mean BP <130/80

0102030405060

perc

ent

Source: Karen Scott-Collins, MD, MPH, Deputy Chief Medical Officer, Health Care Quality and Clinical Services, New York City Health and Hospitals Corporation

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 Physicians’ Participation in Redesign and Collaborative Activities, by Practice SizeCollaborative Activities, by Practice Size

43

20

3339

50

32

47

35

24

34

0

50

100

Redesign Efforts Collaborative Efforts*

Total 10–49 Physicians1 Physician 50+ Physicians2–9 Physicians

* Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years.

33

THE COMMONWEALTH

FUND

Health Policy: Health Policy: Need for LeadershipNeed 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 nation’s health care problems not being considered

34

THE COMMONWEALTH

FUND

Tax Revenues at Lowest Percent of GDP Tax Revenues at Lowest Percent of GDP in 40 Yearsin 40 Years

Note: Actual 1962–2004; Projected 2005–2015.Source: Congressional Budget Office, The Budget and Economic Outlook: Fiscal Years 2006 to 2015, January 2005.

15

16

17

18

19

20

21

22

23

24

1962 1967 1972 1977 1982 1987 1992 1997 2002 2007 2012

Revenues OutlaysPercent of GDP

Actual Projected

Average Outlays,

1962-2004

Average Revenues, 1962-2004

35

THE COMMONWEALTH

FUND

Average Annual Medicaid Spending Growth Per Average Annual Medicaid Spending Growth Per Enrollee Lower Than Private Health Spending, Enrollee Lower Than Private Health Spending,

2000–2003 2000–2003

6.9

9.0

12.6

0

2

4

6

8

10

12

14

Medicaid acute care

spending per enrollee

Health care spending

per person with

private coverage

Monthly premiums for

employer-sponsored

insurance

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

THE COMMONWEALTH

FUND

Higher Deductibles Associated with Greater Higher Deductibles Associated with Greater Access ProblemsAccess 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, 2005.

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

26

2117

42

313135

48

40

0

20

40

60

Total Health Problem** <$50,000 AnnualIncome

Comprehensive HDHP CDHP

37

THE COMMONWEALTH

FUND

Percent of Adults Ages 18–64 UninsuredPercent of Adults Ages 18–64 Uninsuredby Stateby State

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVTNH

MARI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

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

1999–2000 2003–2004

Source: Two-year averages 1999–2000 and 2003–2004 from the Census Bureau’s March 2000, 2001 and 2004, 2005 Current Population Surveys. Estimates by the Employee Benefit Research Institute.

MA

RI

CT

VTNH

MD

38

THE COMMONWEALTH

FUND

Without Insurance it Is Difficult to Obtain Without Insurance it Is Difficult to Obtain Specialized Care 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.

0 20 40 60 80 100

Uninsured patients

Insured patientsCan provide all necessary services

using health center's resources

Can obtain non-emergency admissions

Can obtain specialty referrals

39

THE COMMONWEALTH

FUND

Proportion of U.S. Physicians Providing Charity Proportion of U.S. Physicians Providing Charity Care Is DecliningCare Is Declining

76.368.271.5

0

25

50

75

100

1996-97 2000-01 2004-05

Percent

* Change from 2000-01 is statistically significant at p<.05# Change from 1996-977 is statistically significant at p<.05Source: 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

THE COMMONWEALTH

FUND

Retaining and Expanding Employer Retaining and Expanding Employer Participation: Maine’s Dirigo HealthParticipation: 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 11,000 as of 10/20/05

* After discount and employer payment (for illustrative purposes only).

300600

8881188

1488

1250

0

1000

750

500

250

0$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

MaineCare <150% <200% <250% <300% >300%

Deduc tible amountEmployee share of annual premium

Annual expenditures on deductible and premium

$550

$0

$1,100

$1,638

$2,188

$2,738

41

THE COMMONWEALTH

FUND

Pay for Performance ProgramsPay 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 http://www.leapfroggroup.org/

42

THE COMMONWEALTH

FUND

Building Quality Into RIte CareBuilding Quality Into RIte CareHigher Quality and Improved Cost TrendsHigher 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, 2003. Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005.

Cumulative Health Insurance Rate Trend

Comparison

0

20

40

60

80

100

120

140

160

RI Commercial Trend

RIte Care Trend

Percent

43

THE COMMONWEALTH

FUND

Take Away MessagesTake 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

THE COMMONWEALTH

FUND

Thank You!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