Transcript document

THE
COMMONWEALTH
FUND
Health System Performance:
Challenges for the U.S. and Canada
Karen Davis
President, The Commonwealth Fund
Centre for Health Services and Policy
Research Conference
March 4, 2008
[email protected]
www.commonwealthfund.org
Goals for a High Performance
Health System
HIGH QUALITY
CARE
EFFICIENT
CARE
2
ACCESS AND
EQUITY FOR ALL
LONG,
HEALTHY,
AND
PRODUCTIVE
LIVES
SYSTEM AND
WORKFORCE
INNOVATION AND
IMPROVEMENT
THE
COMMONWEALTH
FUND
3
US Scorecard:
Why Not the Best?
Commonwealth Fund Commission National Scorecard
Long, Healthy &
Productive Lives
69
Quality
71
Access
67
Efficiency
51
Equity
71
OVERALL SCORE
66
0
100
THE
COMMONWEALTH
FUND
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
3
4
Mirror Mirror: US and Canada Fall Behind
Country Rankings
1-2.66
2.67-4.33
4.33-6.0
AUSTRALIA
CANADA
GERMANY
NEW
ZEALAND
UNITED
KINGDOM
UNITED
STATES
3.5
5
2
3.5
1
6
4
6
2.5
2.5
1
5
Right Care
5
6
3
4
2
1
Safe Care
4
5
1
3
2
6
Coordinated Care
3
6
4
2
1
5
Patient-Centered Care
3
6
2
1
4
5
Access
3
5
1
2
4
6
Efficiency
4
5
3
2
1
6
Equity
2
5
4
3
1
6
Long, Healthy, and Productive
Lives
1
3
2
4.5
4.5
6
$2,876*
$3,165
$3,005*
$2,083
$2,546
$6,102
OVERALL RANKING (2007)
Quality Care
Health Expenditures per
Capita, 2004
* 2003 data
Source: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, Mirror,
Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, The
Commonwealth Fund, May 2007
THE
COMMONWEALTH
FUND
5
LONG, HEALTHY & PRODUCTIVE LIVES
Mortality Amenable to Health Care
Deaths per 100,000 population*
1997/98
150
2002/03
130
116
109
99
100
88
81
76
89
84
97
89
65
74
71
77
74
128
115
113
97
88
50
71
115
106
134
80
82
84
84
82
96
93
90
101
103
103
104
110
d
De
Un
nm
ite
ar
d
k
Ki
ng
do
m
Ir e
la
nd
Po
r tu
Un
ga
ite
l
d
St
at
es
al
an
d
Ze
Ne
w
Fi
nl
an
m
an
y
ria
Ge
r
Au
st
ec
e
Gr
e
No
rw
Ne
ay
th
er
la
nd
s
Sw
ed
en
da
ly
Ca
na
It a
n
Sp
ai
ra
lia
Au
st
pa
n
Ja
Fr
an
ce
0
* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.
See Technical Appendix for list of conditions considered amenable to health care in the analysis.
Data: E. Nolte, London School of Hygiene and Tropical Medicine analysis of World Health Organization (WHO)
mortality files.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
THE
COMMONWEALTH
FUND
5
International Comparison of Spending on Health,
1980–2005
Average spending on health
per capita ($US PPP)
7000
6000
United States
Germany
Canada
France
Australia
United Kingdom
6
Total expenditures on health
as percent of GDP
16
14
5000
12
4000
10
8
3000
6
2000
4
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
0
2
0
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
1000
United States
Germany
Canada
France
Australia
United Kingdom
Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of
U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007
OECD data
THE
COMMONWEALTH
FUND
6
Overall Views of the Health Care System
in Seven Countries, 2007 and 1998
AUS
CAN
GER
NETH
NZ
UK
US
2007
24
26
20
42
26
26
16
1998
19
20
*
*
9
25
17
2007
55
60
51
49
56
57
48
1998
49
56
*
*
57
58
46
2007
18
12
27
9
17
15
34
1998
30
23
*
*
32
14
33
Percent reporting:
7
Only Minor
Changes Needed
Fundamental Changes
Needed
Rebuild
Completely
* Germany and the Netherlands did not participate in the 1998 survey.
Sources: 1998 and 2007 Commonwealth Fund International Health Policy Surveys
THE
COMMONWEALTH
FUND
8
Improving Access
• Remove financial barriers to care
• Enroll patients in a patient-centered primary
care “home”
– Standards for a primary care home
•
•
•
•
•
Accessibility
Care coordination
Prevention and health promotion
Chronic disease management
Patient-centered care
– Monitoring performance
– Aligning financial incentives
• Organized system of “off hours” care
coordinated with regular source of care
THE
COMMONWEALTH
FUND
Fewer Canadians Face Cost-Related Access
Problems Than Americans
Percent in past
year due to cost:
AUS
CAN
GER
NETH
NZ
UK
US
Did not fill
prescription or
skipped doses
13
8
11
2
10
5
23
Had a medical
problem but did
not visit doctor
13
4
12
1
19
2
25
Skipped test,
treatment or
follow-up
17
5
8
2
13
3
23
Percent who said
yes to at least
one of the above
26
12
21
5
25
8
37
9
THE
COMMONWEALTH
FUND
Source: 2007 Commonwealth Fund International Health Policy Survey. (Schoen et al. Health Affairs 10/31/07)
Access to Doctor When Sick
or Need Medical Attention
10
Percent
75
55
50
25
0
42
49
53
41
22
30
30
20
10
AUS GER NETH NZ UK CAN US
Same-day appointment
5
4
12
20
AUS GER NETH NZ UK CAN US
Wait of 6 days or more
THE
COMMONWEALTH
FUND
Source: 2007 Commonwealth Fund International Health Policy Survey
11
Over One-Third of Canadians and Americans Report
Difficulty Getting Care on Nights, Weekends,
Holidays Without Going to the Emergency Room
Percent reported very or somewhat difficult
Very Difficult
75
50
Somewhat Difficult
29
34
35
25
0
AUS
GER
28
38
38
CAN
US
26
25
25
28
12
NETH
28
20
NZ
29
UK
THE
COMMONWEALTH
FUND
Source: 2007 Commonwealth Fund International Health Policy Survey
Primary Care Doctors in Canada and U.S. Less Likely
to Have Arrangement for Patients’ After-Hours Care
to See Nurse/Doctor
12
Percent
100
95
90
87
81
76
75
47
50
40
25
0
NETH
NZ
UK
AUS
GER
CAN
Source 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. (Schoen et al.
“On the Front Lines of Care…” Health Affairs, Nov. 2, 2006.
US
THE
COMMONWEALTH
FUND
More Canadians and Americans Visited the
Emergency Room For Condition Doctor Could Have
Treated Than Other Countries
Percent
Any visits
50
Visited ER for condition doctor could have treated if available
39
13
36
33
28
21
25
28
18
16
15
11
5
6
9
8
0
AUS
CAN
GER
NETH
NZ
UK
US
THE
COMMONWEALTH
FUND
Source: 2007 Commonwealth Fund International Health Policy Survey
Only Half of Adults in Canada and U.S. Have a14
Medical Home
Percent
75
61
59
50
45
47
GER
NET
47
48
50
UK
CAN
US
25
0
AUS
NZ
Note: Medical home includes having a regular provider that knows you, is easy to contact, and
coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey
THE
COMMONWEALTH
FUND
Canadians with Chronic Condition Less Likely to 15
Receive a Reminder for Preventive Care, Even With a
Medical Home
Base: Adults with a chronic condition
Percent with reminder
Has medical home
100
50
76
67
75
50
No medical home
63
48
64
54
35
51
44
63
50
49
29
25
0
AUS
GER
NETH
NZ
UK
CAN
Note: Medical home includes having a regular provider that knows you, is easy to contact, and
coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey
US
THE
COMMONWEALTH
FUND
Less Than One in Three Canadians Without a
Medical Home and a Chronic Condition Receive a
Care Plan to Manage Condition at Home
16
Base: Adults with a chronic condition
Percent with care plan
Has medical home
75
No medical home
55
50
47
45
32
24
25
39
36
27
30
19
38
34
25
28
0
AUS
GER
NETH
NZ
UK
CAN
Note: Medical home includes having a regular provider that knows you, is easy to contact, and
coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey
US
THE
COMMONWEALTH
FUND
Engaging Patients and Managing Care
Chronic Care Model and Medical Home Fit
Together
17
• Chronic care model
requires a team, patientcentered approach, IT
support
• Country initiatives
around disease
management or frail
elderly have elements
related to building
medical homes
THE
COMMONWEALTH
FUND
18
Canadian and American Patients Report High Rates
of Any Medical, Medication, or Lab Error
Base: Adults with chronic condition
Percent any medical, medication, or lab error
Has medical home
50
No medical home
30
25
34
30
19
18
26
22
17
11
15
29
17
21
11
0
AUS
GER
NETH
NZ
UK
CAN
Note: Errors include medical mistake, wrong medication/dose, or lab/diagnostic errors. Medical home includes having
a regular provider that knows you, is easy to contact, and coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey. (Schoen et al. Health Affairs 10/31/07)
US
THE
COMMONWEALTH
FUND
Canadian and American Patients with a Medical
Home More Likely to Receive Quality
Care from Doctor
19
Percent rated care received “excellent” or “very good”
Has medical home
100
75
87
No medical home
89
60
50
88
82
86
70
65
59
40
47
49
57
51
25
0
AUS
GER
NETH
NZ
UK
CAN
Note: Medical home includes having a regular provider that knows you, is easy to contact, and
coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey
US
THE
COMMONWEALTH
FUND
Physicians in Canada and U.S. Less Likely to
Participate in Activities to Improve Quality of Care
AUS
CAN
GER
NETH
NZ
UK
US
20
Percent in past two years who:
Participated in
collaborative QI
efforts
58
48
76
70
78
58
49
Conducted clinical
audit of patient
care
76
45
69
46
82
96
70
70
35
41
70
50
Percent reporting their practice:
Sets formal
targets for clinical
performance
26
27
THE
COMMONWEALTH
FUND
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Coordination Problems: Medical Records Not
Available During Visit or Duplicative Tests
Percent reported in
past two years:
21
AUS CAN GER NETH NZ UK US
Test results or records
not available at time
of appointment
11
11
8
7
9
10
15
Duplicate tests:
doctor ordered test
that had already been
done
10
5
15
4
6
5
14
Percent with either
coordination problem
18
15
19
9
12
13
23
THE
COMMONWEALTH
FUND
Source: 2007 Commonwealth Fund International Health Policy Survey
Physicians in Canada and U.S.
Less Likely to Receive
Incentives for Quality
22
Percent of physicians reporting any
financial incentive for quality of care*
100
95
79
75
72
58
50
43
41
30
25
0
UK
NZ
AUS
NETH
GER
CAN
US
* Receive or have potential to receive payment for: clinical care targets, high patient ratings,
managing chronic disease/complex needs, preventive care, or QI activities.
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
THE
COMMONWEALTH
FUND
23
Where are the U.S. and Canada on IT?
Percent reporting 7 or more out of
14 functions*
Percent reporting EMR
100
98
92
100
89
87
79
75
83
72
75
59
50
42
50
28
25
32
23
19
25
8
0
0
NET
NZ
UK
AUS
GER
US
CAN
NZ
UK
AUS
NET
GER
US
*Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests,
prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results;
easy to list diagnosis, medications, patients due for care.
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians in Seven Nations: Australia, Canada,
Germany, Netherlands, New Zealand, UK, and US.
CAN
THE
COMMONWEALTH
FUND
Doctors Reporting Routinely Receiving Alerts24
about Potential Problem with Drug
Dose/Interaction
Percent of physicians
Yes, using a manual system
Yes, using a computerized system
100
10
75
33
50
80
28
25
0
31
10
CAN
23
US
2
6
6
93
87
91
NET
NZ
UK
40
GER
AUS
THE
COMMONWEALTH
FUND
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
25
Denmark Leads the Way In IT and Patient-centered
Primary Care 2006: An Example of High Performance
•
Highest public satisfaction with health system among European
countries
•
Blended primary care payment system: fee for service and medical
home monthly fee per patient
•
Organized off-hours service
•
–
Physicians staff phone banks nights and weekends with
computerized access to patient information; paid for telephone
consultations
–
Physicians staff evening and weekend clinics, and
–
Off-hours service physicians do home visits
Health information technology and information exchange
–
98% of primary care physicians totally electronic health records
and e-prescribing
–
Paid for e-mail with patients
–
All prescriptions, lab and imaging tests, specialist consult
reports, hospital discharge letters flow through a single
electronic portal accessible to patients, physicians, and home
health nurses
–
Specialist payment depends upon filing information in the
electronic portal
THE
COMMONWEALTH
FUND
Take Away Messages
•
26
Country patterns reflect underlying strategic policy choices
– Universal coverage matters
– Having an integrated health care “system” matters
– National leadership on health policy matters
•
Regardless of system characteristics, having a “Medical Home” that is
accessible and coordinates care improves patient experiences
– Patient safety
– Coordination with specialists/across sites of care
– Patient-centeredness and satisfaction
– Managing Chronically Ill patients
– Efficiency: duplication and delays
– After-hours care arrangements
•
Health information technology has significant potential:
– To enhance data availability on which to benchmark and improve
performance
– To improve quality by supporting providers and patients
– To improve care coordination across providers of care
– To improve accessibility of care
THE
COMMONWEALTH
FUND
– To improve physician satisfaction with practice
27
Conclusions
•
No country systematically leads in performance
•
Variations in health system performance offer opportunities
for cross-national learning
•
Managing patients with complex, chronic illnesses is a
shared challenge
•
Primary Care “redesign” and Workforce Strategy
are critical to improving health system performance
•
Making rapid progress requires:
– Learning from best practices within country and across
countries
– Aligning incentives for high value care
– Accountable coordinated care for all patients
– Implementation of electronic information systems
– Accountable leadership
THE
COMMONWEALTH
FUND
28
Thank You!
Stephen C. Schoenbaum,
M.D., Executive Vice
President and Executive
Director, Commission on a
High Performance Health
System, [email protected]
Cathy Schoen, Senior
Vice President for
Research and
Evaluation
[email protected]
Robin Osborn, Vice
President and
Director,
International
Program in Health
Policy and
Practice
[email protected]
Katherine Shea,
Research
Associate
[email protected]
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