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

Why Not the Best? A High Performance Why Not the Best? A High Performance Health System in HawaiiHealth System in Hawaii

Hawaii Uninsured Project Fall ForumOctober 23, 2006

Anne GauthierSenior Policy Director

The Commonwealth Fundwww.cmwf.org

Presentation OverviewPresentation 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 FundThe Commonwealth Fund Commission on a High Performance Health Commission on a High Performance Health

SystemSystem

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 ProductsMajor 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 Commission Conception of High Performing Health SystemPerforming 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:The National Landscape:How are States Performing How are States Performing Compared to Achievable Compared to Achievable

Benchmarks?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

97 97 99106 107109 109

115115

129 130132

7584

88 88 8881

92

0

50

100

150

Deaths per 100,000 population*

110

9384

90

103

119

134

Percentiles

International Variation, 1998 State Variation, 2002

* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart diseaseDATA: International: WHO mortality database from Nolte and McKee 2003; U.S. 2002 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

7.07.4

5.3

6.0

7.1

8.1

9.1

Infant Mortality Rate, 2002Infant Mortality Rate, 2002

* 2001.Data: International estimates—OECD Health Data 2005;State estimates—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2005a).

2.2

3.0 3.03.3 3.5

4.1 4.1 4.1 4.2 4.2 4.4 4.4 4.5 4.55.0 5.0 5.0 5.0 5.1 5.2 5.4 5.6

7.0

0

5

10

Infant deaths per 1,000 live births

International variation State variation

LONG, HEALTHY & PRODUCTIVE LIVES

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

States Vary In Quality of CareStates 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

WA

OR

ID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SC

TNNC

KY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVT

NH

MA

RI

CT

DE

DCCO

GAMS

OK

NJ

SD

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, Preventive Care Visits for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003Race/Ethnicity, Family Income, and Insurance, 2003

35

63

70

58

62

48

73

64

59

49

48

0 50 100

Uninsured

Private insurance

<100% of poverty

400%+ of poverty

Hispanic

Black

White

Bottom 10% states

Top 10% states

Hawaii

U.S. average

Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).


QUALITY: THE RIGHT CARE

Nursing Homes: Hospital Admission and Readmission RatesNursing Homes: Hospital Admission and Readmission RatesAmong Nursing Home Residents, by State, 2000Among Nursing Home Residents, by State, 2000

16

89

12

19

21

0

10

20

30

Median Beststate

10th%ile

25th%ile

75th%ile

90th%ile

Percent

12

78

10

13

16

0

10

20

30

Median Beststate

10th%ile

25th%ile

75th%ile

90th%ile

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 2000.


QUALITY: COORDINATED CARE

13

9 8 9

16

19

14 14 15

2223

18

0

15

30

High-risk residents

Pressure Sores Among High-Risk and Short-Stay Residents in Pressure Sores Among High-Risk and Short-Stay Residents in Nursing FacilitiesNursing 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

White 13% 21%

Black 17 26

Hispanic 15 25

Asian 12 22

AI/AN 17 23

State distribution, 2004 By race/ethnicity, 2003


QUALITY: SAFE CARE

Percent of Adults Ages 18–64 Uninsured by StatePercent 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

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%–22.9%

Less than 14%

14%–18.9%

23% or more

1999–2000 2004–2005

MA

RI

CT

VTNH

MD

NH


ACCESS: UNIVERSAL PARTICIPATION

States with Highest and LowestStates with Highest and LowestAdjusted Health Plan Premiums, 2002Adjusted Health Plan Premiums, 2002

Employee-only adjusted premiums

3,582

2,9812,717

2,8332,9543,203

3,5443,621

4,001

0

1,000

2,000

3,000

4,000

5,000

Wyoming Maine Wisconsin West

Virginia

U.S.

average

Alabama Oregon California Hawaii

Adapted from J. Gabel, R. McDevitt, L. Gandolfo et al., “Generosity and Adjusted Premiums in Job-BasedInsurance: Hawaii Is Up, Wyoming Is Down,” Health Affairs, May/June 2006 25(3):832–43.

Dollars

Medicare Hospital 30-Day Readmission Rates, by Regions, 2003

18

1514

16

20

22

0

5

10

15

20

25

30

National Mean Hawaii 10th 25th 75th 90th

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 DataSOURCE: 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 http://www.nschdata.org).

23

53

58

39

53

36

60

45

46

30

31

0 50 100

Uninsured

Private insurance

<100% of poverty

400%+ of poverty

Hispanic

Black

White

Bottom 10% states

Top 10% states

Hawaii

U.S. average

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*


QUALITY: COORDINATED CARE

Receipt of All Three Recommended Services for Diabetics,Receipt of All Three Recommended Services for Diabetics,by Race/Ethnicity, Family Income, Insurance, and Residence, 2002by Race/Ethnicity, Family Income, Insurance, and Residence, 2002

45

55

54

46

50

61

55

53

54

47

24

38

0 40 80

Rural

Urban

Uninsured

Private

<100% of poverty

100%–199% of poverty

200%–399% of poverty

400%+ of poverty

Hispanic

Black

White

Total

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).

*

**


EQUITY: THE RIGHT CARE

What are States Doing to What are States Doing to Transform Health System Transform Health System

Performance?Performance?

?C

AF

D

Keys to Transforming the U.S. Health Care Keys to Transforming the U.S. Health Care SystemSystem

1. Guarantee affordable health care coverage2. Implement major quality and safety improvements3. Work toward a more organized delivery system that emphasizes

patient-centered primary and preventive care 4. Increase transparency and reporting on quality and costs5. Expand the use of interoperable information technology6. Reward performance for quality and efficiency 7. Encourage public-private collaboration

State Efforts to Guarantee Affordable Health State Efforts to Guarantee Affordable Health Insurance CoverageInsurance 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 CareSystem

• Individual Mandate

• Fair Share Assessment• “Free Rider” provisions• Mandatory “cafeteria

plans”

• Meet quality and performance standards

• New levels of “transparency” • Adjust to payment changes

ExpandedCoverage

Source: Lischko, Amy. October 16, 2006. “Massachusetts Health Reform.” NASHP 19 th Annual State Health Policy Conference, Pittsburgh, PA.

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 14,700 as of 4/30/06

* 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%

Deductible amountEmployee share of annual premium

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-KidsIllinois 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 New Jersey Raises Age of Dependent Status for Health InsuranceStatus 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

11.2 11.812.7 13.4 13.7

0

5

10

15

2000 2001 2002 2003 2004

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 2001–2005 Current Population Surveys)

Millions uninsured, adults ages 19–29

Implement Major Quality and Safety Improvements

2. Implement Major Quality and Safety Improvements


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 Care3. Emphasize Patient-

Centered Primary, and Preventive

Care


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

Care2. Implement Major Quality and Safety Improvements


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

Expand the Use of Interoperable Information Technology

5. Expand the Use of Interoperable Information Technology






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. 06-0057, January 2006.

Reward Performance for Quality and Efficiency

6. Reward Performance for Quality and Efficiency







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

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 Cost Trend

Comparison

0

20

40

60

80

100

120

140

160

RI Commercial Trend

RIte Care Trend

Percent

Encourage Public-Private Collaborationto Achieve Simplification,

More Effective Change

7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change








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” certification2. Adopt and utilize uniform measures of quality and results3. Empower consumers with easy access to information4. Require use of information technology

Expanding Coverage is Only One Piece of the PuzzleExpanding Coverage is Only One Piece of the Puzzle

7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change








Several States Attempting Several States Attempting Comprehensive Health ReformComprehensive 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:Rhode Island:Five-Point StrategyFive-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 H.R. 5684: Health Partnership Through Partnership Through

Creative Federalism ActCreative Federalism Act Rep. Tammy Baldwin (D-WI)Rep. Tammy Baldwin (D-WI) Rep. Tom Price (R-GA)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 S. 2772: Health

Partnership ActPartnership Act

Senator George Voinovich (D-WI)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)Senator Jeff Bingaman (D-NM)

http://en.wikipedia.org/wiki/Image:George_Voinovich_official_portrait.jpg

http://en.wikipedia.org/wiki/Image:Jeff_Bingaman.jpg

Moving Forward

States Can Lead the WayStates 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 All publications are available at http://www.cmwf.orghttp://www.cmwf.org

Visit the Fund at:http://www.cmwf.org

AcknowledgementsStephen C. Schoenbaum Executive Vice President for Programs

Karen DavisPresident

Ilana WeinbaumProgram Associate

Sabrina HowResearch Associate

Cathy Schoen Senior Vice President for Research and Evaluation

Alyssa HolmgrenResearch Associate

Documents

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