Transcript What You Measure Matters: Monitoring and Tracking Health

Aiming for a Higher Performing Health Care System:
Learning from Cross-National Comparisons
Queen’s Health Policy Change Conference
May 6, 2015
Toronto, Canada
Robin Osborn
Vice President and Director
International Program in Health Policy and Practice Innovations
The Commonwealth Fund
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What is a High Performing Health System?
• Goals of a High Performance Health System
• Best possible health outcomes for everyone
• Access to care for all
• Excellent patient experiences – patient-centered,
coordinated, high quality, safe care for all
• Lower cost – accountable for use of resources and
elimination of waste
• Encourages innovation
• Learning health care system
Why Should We Look at Other Country Health Care Systems?
“Americans have the best health care system in the
world” - 2004
President Delivers State of the Union Speech
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Why Do We Do Cross-National Comparisons?
• Benchmark performance
• Track policies and reforms
• Highlight best practices
• Identify variations
• Know what is possible
Health Care Spending as a Percentage of GDP, 1980–2012
Percent
US (16.9%)
18
NET (12.1%)*
16
FR (11.6%)
14
SWIZ (11.4%)
GER (11.3%)
12
DEN (11.0%)
10
CAN (10.9%)
JPN (10.3%)
8
NZ (10.0%)*
6
SWE (9.6%)
4
NOR (9.3%)
UK (9.3%)
2
AUS (9.1%)*
0
1980
1983
1986
1989
* 2011
GDP refers to gross domestic product.
Source: OECD Health Data 2014.
1992
1995
1998
2001
2004
2007
2010
5
6
Mortality Amenable to Health Care, 2006-07
Deaths per 100,000 population*
140
120
96
100
76
80
60
55
57
60
FR
AUS
ITA
61
61
64
79
80
83
NZ
DEN
UK
66
40
20
0
JPN SWE NOR NETH GER
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke,
and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S.
Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income
Nations,” Health Policy, published online Sept. 12, 2011.
US
Overall Views of Health Care System, 2013
Percent
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
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Learning from International Surveys
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Commonwealth Fund Annual International Surveys:
What We Track
• General themes:
– Views of the health system
– Access and affordability
– Primary care/Medical home
– Doctor-patient relationship
– Prevention/health promotion
– Care coordination
– Electronic Health Record
– Patient safety
–
–
–
–
–
–
–
–
–
QI/Performance feedback
Chronic illness
Use of the ED
Hospital care
Medications
Physician payment/Incentives
System complexity
Health care coverage
Demographics
• Focus on objective measures rather than opinions.
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Access and Affordability
11
Cost-Related Access Problems in the Past Year,
Among Adults Age 65 or Older
Percent*
30
19
20
10
3
4
4
FR
SWE
NOR
5
6
6
UK
NETH
SWIZ
7
8
GER
AUS
9
10
CAN
NZ
0
* Had a medical problem but did not visit doctor, skipped medical test or treatment recommended
by doctor, and/or did not fill prescription or skipped doses because of the cost.
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
US
12
Could Get Same- or Next-Day Appointment with Doctor or Nurse
When Sick or Needed Care, Among Adults Age 65 or Older
Percent
100
83
83
81
76
80
71
69
65
57
60
54
53
45
40
20
0
FR
NZ
GER
NETH
AUS
SWIZ
UK
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
US
NOR
SWE
CAN
Waited Less Than Four Weeks for Specialist Appointment,
Among Adults Age 65 or Older
Percent*
100
86
82
80
71
64
62
61
60
60
60
50
46
46
CAN
NOR
40
20
0
US
SWIZ
NETH
AUS
NZ
GER
FR
* Base: Saw/Needed to see a specialist in the past two years.
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
UK
SWE
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14
Access to After-Hours Care,
Among Adults Age 65 or Older
Percent who said it was somewhat or very easy to get after-hours care
without going to the emergency department*
100
80
77
71
69
69
66
66
62
55
60
54
41
40
37
20
0
NETH
UK
FR
NZ
SWIZ
NOR
GER
* Base: Needed after-hours care.
Source: 2012 and 2014 Commonwealth Fund International Health Policy Surveys.
US
AUS
CAN
SWE
15
Emergency Department Use in the Past Two Years,
Among Adults Age 65 or Older
Percent
50
40
33
30
19
20
27
27
NOR
SWIZ
29
30
NETH
AUS
39
39
CAN
US
35
21
15
10
0
FR
UK
GER
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
NZ
SWE
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Care Coordination and Transitions
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Experienced a Coordination Problem in the Past Two Years,
Among Adults Age 65 or Older
Percent*
50
41
40
35
29
30
20
10
20
21
21
NZ
NETH
AUS
24
24
UK
SWE
37
32
7
0
FR
SWIZ
* Test results/records not available at appointment or duplicate tests ordered; received
conflicting information from different doctors; and/or specialist lacked medical history or
regular doctor was not informed about specialist care.
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
CAN
US
NOR
GER
18
Experienced Gaps in Hospital Discharge Planning in the
Past Two Years, Among Adults Age 65 or Older
Percent*
100
80
67
60
38
40
41
44
AUS
CAN
54
56
56
59
FR
SWIZ
GER
NETH
70
28
20
0
US
UK
SWE
NOR
* When discharged from the hospital: you did not receive written information about what to do when you returned home and
symptoms to watch for; hospital did not make sure you had arrangements for follow-up care; someone did not discuss with
you the purpose of taking each medication; and/or you did not know who to contact if you had a question about your condition
or treatment. Base: hospitalized overnight in the past two years.
Note: NZ omitted because of small N (fewer than 100 respondents).
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
Primary Care Doctors’ Receipt of Information from Specialists
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Percent who reported after their patient visits a specialist they always receive information
about changes to patient’s drugs or care plan
80
60
47
44
44
41
40
30
24
22
20
16
13
12
5
0
FR
NZ
SWIZ
UK
AUS
CAN
NOR
US
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
SWE
GER
NETH
20
Chronic Care and Self-Management
21
Patient Engagement in Chronic Care Management,
Among Adults Age 65 or Older
Percent who have a chronic condition and had a treatment plan for their condition they
could carry out in their daily life
100
83
80
80
76
73
64
60
62
53
47
41
41
40
30
20
0
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
Support for Self-Management Between Doctor Visits,
Among Adults Age 65 or Older
22
Percent who have a chronic condition and had a health care professional that between
doctor visits:
Contacts them to check in
They can contact to ask questions or
get advice
100
84 83
75 75
80
67 65
58
60
47
55 53
43
40
30 28
20
71
24 24 23
17 16 15
14
9
0
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
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Medical Homes
Patients with a Regular Doctor versus a Medical Home, 2011
Percent
Patients with a medical home have a regular practice who is accessible,
knows them, and helps coordinate their care
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
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Medical, Medication, or Lab Test Errors in Past Two Years,
by Medical Home
Percent*
* Reported medical mistake, medication error, and/or lab test error or delay in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
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Primary Care Practice Infrastructure and
Capacity for Improvement
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Percent
Doctors’ Use of Electronic Medical Records
in Their Practice, 2009 and 2012
Source: 2009 and 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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Doctor Can Electronically Exchange Patient Summaries
and Test Results with Doctors Outside their Practice
Percent
100
80
60
55
52
49
49
45
39
40
38
31
27
22
20
14
0
NZ
SWE NETH SWIZ
NOR
FRA
UK
US
AUS
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
GER
CAN
29
Doctor Routinely Receives Electronic Prompts About
Potential Problems with Rx Dose or Interaction
Percent
100
93
89
88
85
80
70
58
60
41
40
30
26
25
GER
SWIZ
22
20
0
NETH
NZ
AUS
UK
SWE
US
FRA
CAN
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
NOR
30
Percent
Practice Uses Nurse Case Managers or Navigators
for Patients with Serious Chronic Conditions
100
80
78
73
68
68
59
60
51
44
43
41
40
20
20
0
UK
NETH
NZ
SWIZ
AUS
NOR
CAN
US
Note: Question asked differently in France.
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
SWE
GER
Practice Routinely Receives and Reviews Data on Clinical Outcomes
Percent
100
84
81
80
78
64
60
54
47
42
40
23
20
14
12
FR
SWIZ
0
UK
NETH
SWE
NZ
GER
US
AUS
CAN
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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32
Financial Incentives and Targeted Support
Percent can
receive financial
incentives* for:
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Managing patients
w/ chronic
disease or
complex needs
75
70
37
60
77
83
15
49
4
50
21
Enhanced
preventive care
activities**
42
42
12
23
28
40
17
55
5
37
14
Adding
nonphysician
clinicians to
practice
53
33
3
5
60
36
9
33
4
17
10
Making home
visits
57
53
16
51
50
36
45
49
32
20
9
* Including special payments, higher fees, or reimbursements.
** Including patient counseling or group visits.
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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Policy Implications
•
Insurance design matters
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Having a “medical home” and after-hours care arrangements make a difference
•
Innovations in payment and delivery system models are needed to encourage
care coordination and better management of complex patients
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Chronically ill patients need to be further empowered and supported in selfmanagement, including between scheduled visits
•
Having electronic medical records is not enough – “meaningful use” matters
•
More use of performance data and feedback are needed to help primary care
practices improve care and patient experiences
•
And, as countries innovate and transform their health care systems, there is a
tremendous opportunity for cross-national learning
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Limitations of Current Cross-National Comparisons
•Numbers don’t tell the full story
• Imperfect performance measures:
o Outcome indicators are scarce
o Few measures of hospital quality
o Data does not always lead to a value judgment (e.g., are
more MRI machines good or bad?)
• Proliferation of country measures but not typically adopted
based on international comparability
• We need more patient-reported outcome measures
• Good News: the OECD Health Quality Indicators/Health at a
Glance portfolio is expanding and very relevant
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Monitoring & Tracking Performance:
U.S. Efforts
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Overall Health System Performance, 2014
Ranking based on access & affordability, prevention & treatment,
avoidable hospital use and cost, healthy lives, and equity
Source: The Commonwealth Fund State Scorecard
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Long Term Supports:
Overall Health System Performance, 2014
Ranking based on access & affordability, choice of setting and provider, quality of life and quality of
care, support for family caregivers, and effective transitions
Source: The Commonwealth Fund Scorecard on Long Term Support Services
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Quality: Mortality Amenable to Health Care,
by Race and State, 2009-10
Source: Commonwealth Fund State Scorecard on State
Health System Performance, 2014
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Access: Out-of-Pocket Mean Expenditures, by Race/Ethnicity
Annual out-of-pocket mean expenditures by race/ethnicity
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household
Component of the Medical Expenditure Panel Survey, 2012
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Quality: Preventable Hospitalizations in New York State,
by County
Age Adjusted Preventable Hospitalizations Rate per 10,000, Ages 18+ Years, 2008-10
1st & 2nd Quartiles
(<144 per 10,000)
3rd Quartile
(144-<162 per 10,000)
4th Quartile
(162+ per 10,000)
Source: Health Data NY
The Prevention Quality Indicators (PQIs) are a set of measures developed by the federal Agency for Healthcare Research and Quality (AHRQ) for use
in assessing the quality of outpatient care for "ambulatory care sensitive conditions" (ACSCs). This indicator is defined as the combination of the 12
PQIs that pertain to adults: (1)Short-term complication of diabetes (2)Long-term complication of diabetes (3)Uncontrolled diabetes (4)Lower-extremity
amputation among patients with diabetes (5)Hypertension (6)Congestive heart failure (7)Angina (8)Chronic obstructive pulmonary disease (9)Asthma
(10)Dehydration (11)Bacterial pneumonia (12)Urinary tract infection.
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Quality: Readmission Rates, by Hospital
Heart Failure 30 Day Readmission Rate, by Hospital, 2010-13
Percent
High Performing Hospitals*
Source: CMS Hospital Compare
Low Performing Hospitals**
* Examples from top 10% of hospitals
**Examples from bottom 10% of hospitals
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Quality: Falls in Long Term Care Institutions,
by Nursing Home
Percent of Long-Stay Residents Experiencing One or More Falls with Major Injury, 2014
Percent
High Performing Nursing Homes*
Source: CMS Nursing Home Compare
Low Performing Nursing Homes**
* Examples in top 10% of nursing homes
** Examples from bottom 10% of nursing homes
Acknowledgements
With appreciation to Dana Sarnak, David Squires, and Michelle Doty for their
contributions to this presentation.
And, to our International Survey Partners for their support and expertise:
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Australia: New South Wales Bureau of Health Information
Canada: Canadian Institute for Health Information, Canadian Institutes of
Health Research, Health Quality Ontario, Commissaire à la Santé et au Bienêtre du Québec, and Health Quality Council of Alberta
France: Haute Autorité de Santé and Caisse Nationale d’Assurance Maladie
des Travailleurs Salariés
Germany: Federal Ministry of Health and the German National Institute for
Quality Measurement in Health Care
Netherlands: Ministry of Health, Welfare, and Sport and the Scientific Institute
for Quality of Healthcare at Radboud University Nijmegen Medical Centre
Norway: Norwegian Knowledge Centre for the Health Services
Sweden: Ministry of Health and Social Affairs
Switzerland: Federal Office of Public Health
United Kingdom: The Health Foundation