Transcript Achieving a High Performance Health Care System: Applying

Achieving a High Performing
Health Care System:
Applying Lessons from Other
Countries to U.S. Health Care
David C. Dale MD, FACP
J. Fred Ralston, Jr. MD, FACP
Robert B. Doherty
American College of Physicians
Based on a Presentation to the National Congress on
the Un and Underinsured
December 11, 2007
Introduction
 What is the American College of
Physicians?
• 124,000 Doctors of Internal Medicine
and Medical Students
• The Second Largest Medical
Organization in the USA
• The Largest Medical Specialty
Society
What Did We Do?
 Analyzed the US Health Care System
 Evaluated According to Commonwealth
Fund Criteria for Measuring Performance
 Analyzed Health Care Systems in 12 Other
Countries
 Compared the US Health Care System to
Systems in Other Countries
 Determined Lessons From Other Countries
 Issued Recommendations for Achieving a
High Performance Health Care System
Why Did We Do It?
 ACP has Advocated for Universal Health
Insurance Coverage Since 1990
 Previous Efforts By ACP and Others Have
Focused on Improving Specific Aspects of
Health Care
 Systemic Changes Are Needed
 Goal to Achieve a High Performance Health
Care System With Universal Access
 Lessons Can Be Learned from Successful
Health Care Systems in Other Countries
The Cost of Health Care in the US
 National Health Expenditures in 2005 =
• $2.0 Trillion
• $6,697 per person
• 16% of GDP
 Health Insurance Costs Continue to Rise
• Health Spending is Rising Faster Than Inflation
and Economic Growth
• Employers Are Reducing or Dropping Coverage
• Health Spending is Projected to Reach $4.0
Trillion (20% of GDP) by 2015
Paying for Health Care in the US
Other
6%
Other Gov't
13%
Private Ins.
35%
Out-ofPocket
13%
Medicaid
16%
Medicare
17%
Health Insurance Coverage in the US
 250 Million Have Health Insurance
(84.2%)
 47 Million (15.8%) Uninsured All Year
 89.5 Million (34.6%) Uninsured 1 Month
or More
 Another 16 Million Under-Insured
People Without Health Insurance are:
 Less Likely to Receive Preventive Services
and Medications
 Less Likely to Have Access to Regular
Care by a Personal Physician
 Less Able to Obtain Needed Health Care
Services
 More Likely to Suffer Complications for
Preventable Illnesses
 More Likely to Die Prematurely
Chronic Health Conditions
 120 Million Americans (45%) Have at Least 1
Chronic Condition
 60 Million Have Multiple Chronic Conditions
 83% of Medicare Beneficiaries Have 1 or More
 23% of Medicare Have 5 or More
 By 2015, 150 Million Will Have at Least 1
Chronic Condition
The Increasing Elderly Population
70000
60000
50000
40000
65-84 years old
85 and older
30000
20000
10000
0
2000
2010
2020
2030
2040
2050
Source: U.S. Census Bureau, “U.S. Interim Projections by Age, Sex, Race, and
Hispanic Origin,” <http://www.census.gov/ipc/www/usinterimproj/>
As Patients Age They Require More
Visits to the Doctor
Physician Workforce
 The Supply of Primary Care Physicians Will
Not Keep Pace with the Aging Population
 Already Anecdotal Evidence of Shortages
 As the Population Over Age 65 Increases
More Doctors Will be Needed
 High Student Debt and a Dysfunctional
Payment System are Deterring Physicians
from Primary Care Careers
 The Physician Workforce Is Also Aging:
250,000 Active Physicians Are Over Age 55
Interest in Entering Primary Care has been
Declining Among Graduating Seniors
(Percentages 1999-2006)
14
12
10
GIM
IM SS
FP
PED
8
6
4
2
0
1999
2000
2001
2002
2003
2004
2005
2006
Source: AAMC Medical School Graduation Questionnaires: All School Reports
2000-2006, Choice of Specialty/Subspecialty.
http://www.aamc.org/data/gq/allschoolsreports/2006.pdf
Equity and Utilization
 Wide Variations in Costs
 Wide Differences in Volume and Intensity
of Services Among Areas
 Outcomes No Better in High Cost Areas
 Disparities in Access and Quality Based
on Race and Income
The System is Costly and Inefficient
 Payers Are Straining to Reduce Costs
 Cost Sharing Increasing
 Rise of Consumer-Directed Health Plans
 Increasing Out-of-Pocket Costs
 High Administrative Costs
 High Regulatory Burden
A big caveat
 Any solution for the United States will be
unique to our political and social culture,
demographics, and form of government
• Larger and more diverse population
• Tradition of individualism and distrust of the
federal government
• Constitution limits the power of the federal
government, requires that authority be shared
between federal and state governments, and
protects commercial and individual free speech
• Deeply rooted system of employer-based
coverage, tied to a powerful industry invested in
maintaining private insurance and employerbased coverage
So why study other countries’
experiences?
 Goal should not be to replicate other
countries’ experiences
 But to identify approaches that the
evidence shows are more likely to be
effective
 So that they can inform the political debate
in the United States
 And be adapted to the unique
circumstances in the U.S.
Lesson: All high performing systems
have universal coverage
 Universal: every person is guaranteed,
by law, access to affordable coverage
through a public or private plan and is
required to obtain coverage
 Some have a system funded solely by
the national or provincial governments
(single payer)
 Others use a mix of public and private
funding (pluralistic); coverage is
compulsory and guaranteed
Canada
UK
Japan
Taiwan
Australia
Belgium
Denmark
France
Germany
Netherlands
New
Zealand
Switzerland
Lesson: Global budgets and price controls
can restrain costs but can have negative
consequences
 Global budgets can restrain costs.
but do not improve efficiency
unless the budget is reasonable
and the target region is small
enough to motivate individual
providers
 Price controls can restrain costs,
but may lead to
• delays for elective procedures, costshifting and
• creation of parallel private sector
markets
Canada
Germany
New Zealand
Taiwan
United
Kingdom
Belgium
Canada
Japan
UK
Japan
New Zealand
UK
Recommendation: U.S. must provide
universal coverage
 Guarantee by law that all people within the
United States have equitable access to
appropriate health care without
unreasonable financial barriers
• Health insurance coverage and benefits should
be continuous and not dependent on place of
residence or employment status
 U.S. should consider adopting either a
single payer or pluralistic model with
guaranteed coverage
Single payer or pluralistic systems are both
capable of achieving universal coverage
 Single-payer systems can achieve
universal access to health care without
barriers based on ability to pay
 Pluralistic systems can assure universal
access, but must provide (1) a legal
guarantee that all individuals have access
to coverage and (2) sufficient government
subsidies and funded coverage for those
who cannot afford to purchase coverage
through the private sector
Either has tradeoffs that the public will
need to weigh in making a choice
 Single-payer: more equitable, lower administrative
costs, lower per capita health care expenditures,
high levels of consumer/patient satisfaction and
high performance on measures of quality and
access
•
May create shortages of services, delays in obtaining
elective procedures and limit individuals’ choices
 Pluralistic with guaranteed coverage: allows
individuals the freedom to purchase supplemental
coverage and services
• More likely to result in inequities in coverage and
higher administrative costs
Lesson: Primary care is the foundation
of high performing delivery systems
 Societal investment in medical education,
can help achieve a workforce that has the
right proportion of primary care physicians
and specialists, is well-trained, and is large
enough to assure access
 Investment in primary and preventive care
can result in better health outcomes,
reduce costs, and help assure an adequate
supply of primary care physicians
 These efforts can be enhanced by assuring
that all residents have equitable access to
a patient-centered medical home model
France
Germany
United
Kingdom
Australia,
Canada,
Denmark
France
Netherlands
New Zealand
Switzerland
UK
Denmark
Recommendation: U.S. policy should
support the value of primary care
 Federal government should intervene to
avert the impending catastrophic shortage
of primary care physicians
 U.S. should set specific targets for
producing generalists and specialists and
enact policy to achieve those targets
 Support care that builds upon the
relationship between patients and their
primary care physicians and financially
supports the patient-centered medical
home
Lesson: High performing systems encourage
patients to be prudent purchasers and
engage in healthy behaviors
Belgium
 Cost-sharing with co-payment
schedules based on income can help
restrain costs while assuring that
poorer individuals are still able to
access services
 Incentives to encourage personal
responsibility can be effective in
influencing healthy behaviors,
improved health outcomes and
responsible utilization, without
punishing people who fail to adopt
recommended behaviors or lifestyles
France
Japan
New Zealand
Switzerland
Australia
Belgium
Japan
New Zealand
Netherlands
Switzerland
Taiwan
Recommendation: The U.S. should use
financial incentives for individuals to be
prudent purchasers
 Patients should have ready access to
health information necessary for informed
decision-making
 Cost-sharing provisions should be
designed to encourage patient costconsciousness without deterring patients
from receiving needed and appropriate
services or participating in their care
Lesson: High performing systems
continuously measure how well they do and
link payment to performance
Performance measures,
financial incentives
linked to quality, and
active monitoring of
performance are key
elements of health
systems that provide
high quality care
Australia
New Zealand
United
Kingdom
Lesson: The best payment systems recognize
the value of care coordinated by primary care
physicians
 Effective payment systems:
Belgium
• Provide adequate payment for
primary care services
United
Kingdom
• Create incentives for quality
improvement and reporting
• Recognize geographic or local
payment differences
• Provide incentives for care
coordination
Canada
Denmark
Germany
United
Kingdom
Denmark
Netherlands
Recommendation: U.S. should align
payments to physicians with quality and care
coordination
 Provide financial incentives for physicians
to achieve evidence-based performance
standards
 Revise existing volume-based payment
systems used by Medicare and most
private insurers to
• create care coordination payments for
physicians working with health care teams to
provide patient care management
• maintain a fee-for-service component for
separately-identifiable visits
(modeled on a bundled and hybrid payment
model used in Denmark and the Netherlands)
Lesson: High performing systems invest in
HIT, have uniform billing, and lower
administrative costs
Germany
 Adoption of a uniform billing system
and electronic processing of claims
improves efficiency and reduces
administrative expenses
 An inter-operable health information
infrastructure will enable physicians
to obtain instantaneous information
at the point of medical decisionmaking and enhance electronic
communications among physicians,
hospitals, pharmacies, diagnostic
testing laboratories, and patients
Canada
Taiwan
United Kingdom
and most others
Denmark
Taiwan
Netherlands
Lesson: High performing systems invest in
research and comparative effectiveness
 Insufficient investments in research
and medical technology result in
reliance on outdated technologies and
medical equipment, and delay patients’
access to advances in medical science
 Some countries with national health
insurance programs have achieved
better results (benefit and cost)
through evidence-based evaluations of
new drugs and technology
Canada
United
Kingdom
UK
Australia
Recommendation: The U.S. should invest in
research to foster continued innovation and
improvements in health care
 Funding should come from both
public and private sources
 Increase investment in basic health
research to advance medical
knowledge
 Increase funding for health services
and comparative effectiveness
research
Summary
 The U.S. can learn much by studying what works
well in other countries and by applying those “best
practices” to the U.S.’s distinctive political system,
values and culture
 No single system studied is perfect—each has
trade-offs. In general:
• Single payer systems have lower administrative
costs, high quality, and satisfaction but cost controls
may create shortages and delays
• Pluralistic systems can be designed to achieve
universal coverage with individual freedom to
purchase additional services, but are less equitable
and have higher administrative costs
 The evidence shows that either option merits
consideration by the U.S.
Conclusion:
A high performing U.S. health care system
would be one that:
 Achieves universal coverage (single payer
or pluralistic with guaranteed coverage)
 Is built on a foundation of primary care,
supported by workforce and payment
policies
 Provides patients with access to a patientcentered medical home
 Pays physicians for care coordination and
quality instead of volume
Conclusion:
A high performing U.S. health care system
would be one that:
 Creates positive and non-punitive
incentives for individuals to be “prudent
purchasers” and engage in healthy
behavior
 Measures and reports on its own
performance
 Has uniform billing and lower
administrative costs
 Has high levels of public and private
investment in research (basic, health
services, and comparative)
The 47 million (uninsured) question:
What can we do together to assure
that the 2008 elections creates a
debate on how to achieve a high
performing health care system. . .
. . . So that the next President and
Congress have a political mandate to
learn from other health systems and
adapt their best practices to the United
States?