How Health Services Research Was
Used in Health Care Reform
Cathy Schoen, The Commonwealth Fund
Jonathan Gruber, Massachusetts Institute of Technology
Mark McClellan,
McClellan The Brookings Institution
Jack Ebeler, Health Policy Alternatives
Elizabeth Fowler, Senate Finance Committee
K
Karen
D
Davis,
i Th
The Commonwealth
C
lth Fund
F d
AcademyHealth Annual Research Meeting
June 28,, 2010
Research
R
h in
i Action:
A ti
Health
H lth Services
S
i
Research
R
h
to Inform and Stimulate Health Care Reforms
Cathy
y Schoen
Senior Vice President,
The Commonwealth Fund
www.commonwealthfund.org
lthf d
AcademyHealth Annual Research Meeting
June 28, 2010
3
Fund-Supported Research to Identify Need for Reform and
Potential for Positive Change
• Commission for a High Performance Health System
– Framework: access, quality/outcomes, efficiency
– Scorecards: international comparisons and internal
– Insurance reform and access: essential foundation
– Payment and delivery system reform
• Policy: Potential of comprehensive reforms
– Bending the Curve (Dec. 2007)
– Building
g Blocks: Public & Private Choices (May
( y 2007))
– Path to a High Performance Health System (Feb.
(
2009))
2009)) and Fork in the Road (June
4
Making the Case for Comprehensive Reform
5
Path to a High Performance Health System
• Goals of reform
– Pursuit of triple aim: access,
access quality,
quality and costs (value)
– Focus on improving population health
– Capacity
p
y to improve
p
and innovate
• Coherent strategies: whole-system approach
– Coverage
C
ffoundation
– Payment reform to align incentives with quality/efficiency
– Primary care and delivery system transformation
– Information systems and population health
• Indicators to track and monitor & set benchmarks to improve
• Leadership/collaboration: goals and shared direction
Path Report: Potential to Bend the Cost Curve + Improve
Projected Spending Under Current and Alternative Scenarios
NHE in trillions
$6
Current projection (6.7%annual growth)
$5
Path proposals (5.5%annual growth)
52
5.2
Constant (2009) proportion of GDP (4.7%annual growth)
4.6
$4
4.2
$3
2.6
$2
Cumulative reduction in NHE through 2020: $3 trillion
$1
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Note: GDP = Gross Domestic Product.
Data: Estimates by The Lewin Group for The Commonwealth Fund.
Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way,
February 2009.
6
7
Major Features of Path/Fork and New Health Reform Law
Path/Fork in Road
Health Reform Law


Lower of 7% of earnings or
$2500 per employee
$2000 per employee for employers 50+ employees
not offering coverage
Rules on enrollment, premiums, and
consumer protections
Rules on enrollment, premiums,
medical loss, consumer protections
National, Public plan option,
start in 2010
State, start in 2014
Comprehensive; 84% actuarial value
Comprehensive; 70% actuarial value
Income-related Premium and
Cost Sharing;
Medicaid Expansions
0-12% of income sliding scale premium caps
up to 28% tax bracket;
M di id tto 150% poverty
Medicaid
t
2-9.5% of income up to 400% FPL;
Medicaid to 133% poverty
Payment Reform
Voluntary Medicare payment innovations—
Mandatory Medicare/public payment reform—
ACOs, Medical Homes,
ACOs, Medical Homes,
10% increase in primary care,
5% increase in primary care,
1% productivity improvement,
1% productivity improvement,
Medicaid primary care at Medicare levels, CMS
Medicaid at Medicare levels; Rx prices
Payment Innovation Center, Independent Payment
Advisory Board
I di id l M
Individual
Mandate
d t
Employer Shared Responsibility
I
Insurance
Market
M k tR
Rules
l
Insurance Exchanges
Benefit
f Standard
S
System Reform
Comparative effectiveness tied to benefit
design; HIT;
Medicare Advantage reform
Comparative effectiveness research; HIT;
Medicare Advantage reform
Underinsured: 25 Million U.S. Adults Underinsured in 2007
60 Percent Increase Since 2003
Uninsured
during the year
45 5
45.5
(26%)
Insured all year,
not
underinsured
110.9
(65%)
Uninsured
during the year
49 5
49.5
(28%)
Insured all year,
not
underinsured
102.3
(58%)
Insured
all year,
underinsured*
25.2
(14%)
Insured
all year,
underinsured*
d i
d*
15.6
(9%)
2003
2007
Adults
Ad
l ages 19–64
19 64
(172.0 million)
Adults
Ad
l ages 19–64
19 64
(177.0 million)
*Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or
more of income; medical expenses equaled 5% or more of income if low
low-income
income (<200% of poverty); or deductibles
equaled 5% or more of income.
Data: The Commonwealth Fund Biennial Health Insurance Surveys (2003 and 2007).
Source: C. Schoen et al., “How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007,” Health Affairs
Web Exclusive, June 10, 2008.
8
9
Rite of Passage: Young and Uninsured
• Since 1999,
1999 Fund has tracked
number of young adults
without health insurance,
causes, and effects
Millions Uninsured,
Adults Ages 19–29
15
12.3
10 9
10.9
13.0 12.9 13.3
13.7
13.2
13.7
11.4
10
• Potential to insure up to 13.7
million uninsured young
adults
5
0
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
• Health reform law extends
d
dependent
d t coverage up to
t
age 26 for young adults on
their parents
parents’ plans effective
Sept. 2010
Data: Analysis of the 2001–2009 Current Population Surveys by N. Tilipman, B. Sampat, S. Glied,
and B. Mahato of Columbia University for The Commonwealth Fund.
Source: S. R. Collins and J. L. Nicholson, Rite of Passage: Young Adults and the Affordable Care Act of 2010, The
Commonwealth Fund, May 2010.
10
Improving Primary Care: What is a Medical Home?
• A place where patients
receive enhanced access
to primary care that is
efficiently coordinated by
a clinical team
• Patients actively engaged
(treatment decisions,
quality improvement)
• Practice uses decisionsupport tools, assesses
performance & receives
payment support
• Linked to care continuum
2020 Vision
Accessible
Patient Centered
C
Coordinated
di t d Care
C
11
Overview of Activity
• 27 multi
multi-stakeholder
stakeholder
and pilots in 18 states
• 44 states + DC passed
over 330 laws &/or
have PCMH activity
y
• Medicaid and Medicare
activity
y
• March 2010 Reform:
multiple
p supports
pp
Source: PCPCC Medical Home Briefing - May 4th 2010,
http://www.pcpcc.net/content/general-presentation-materials
11
12
Geisinger Medical Home Sites and
Hospital Admissions/Readmissions
Hospital admissions per 1,000 Medicare patients
Medical Home
Non-Medical Home
Readmission Rates for All
Medical Home Sites
25
20
450
425
400
375
350
325
300
19.5
15.9
15
10
5
0
CY 2006
CY 2007
CY 2006
• 20% reduction in hospital admissions
• 18.5% reduction in hospital readmissions
• 7% total medical cost savings
Source: Geisinger Health System, 2008.
CY 2007
Outcome
measures;
large % of
total payment
Global
Payment
Shared
Savings
Less
Feasible
Care
coordination
and
intermediate
outcome
measures;
moderate % of
total payment
Global Case
Rates
More
Feasible
Blended
FFS/Care
Management fee
Fee-forService
Small practices;
unrelated
hospitals
p
Independent Practice
Associations; Physician
Hospital
p
Organizations
g
Simple process
and structure
measures; small
% of total
Fully integrated
payment
delivery system
Continuum of Organization
Source: Adapted from A. Shih et al., Organizing the U.S. Health Care Delivery System for High Performance,
The Commonwealth Fund, August 2008.
Continuu
C
um of P
P4P Des
sign
Co
ontinuu
um of Pa
ayment Bundling
The Relationship Between
Payment Methods and Organizational Models
13
14
Affordable Care Act: Stimulus for Action
• Medical home: expansion of current Medicare demo;
new pilots, Medicaid initiatives
• Bundled payments: Medicare pilots for hospital and
post-acute care; readmission; Medicaid initiatives
• Accountable Care Organizations 2012: broad
responsibility for quality and cost; shared savings
• Platform for Medicare/private to join multi-payer
multi payer efforts
• Center for Medicare & Medicaid Innovation
15
Summary: Health Care Research to Inform Action
• Focus on assessing problem and potential to improve
– Monitor change and identify promising models
– Assess source of barriers to spread
• Whole-system
Whole system perspective
– Markets and incentives
– Organization of delivery system and performance
– Policy implications
• Model potential of comprehensi
comprehensive
e reforms
– Insurance; payment; delivery system; public health
– Dynamic
D
i change:
h
reforms
f
interact
i t
t over time
ti
• Looking forward: implement well; all-payer coherence
16
Visit the Fund’s website at
www commonwealthfund org
www.commonwealthfund.org
17
Thank You!
Karen Davis
President
Stephen Schoenbaum
Executive Vice President
Executive Director, Commission on
a High Performance Health System
Stu Guterman
Assistant Vice President,
P
Payment
t System
S t Reform
R f
Sabrina How
Senior Research Associate
18
References and Further Reading
• S. Guterman, K. Davis, K. Stremikis, and H. Drake, "Innovation in
Medicare and Medicaid Will Be Central to Health Reform's Success,"
Health Affairs, June 2010.
• Commission on a High Performance Health System, The Path to a High
P f
Performance
U.S.
U S Health
H lth System:
S t
A 2020 Vision
Vi i andd the
th Policies
P li i to
t Pave
P
the Way, The Commonwealth Fund, Feb. 2009.
• C
C. Schoen
Schoen, K.
K Davis,
Davis et al
al. Fork in the Road: Alternatives Paths to a High
Performance Health System, The Commonwealth Fund, June 2009
• C. Schoen, et al., Bending the Curve: Options for Achieving Savings
and Improving Value in U.S. Health Spending, The Commonwealth
Fund, Dec. 2007
• D. McCarthy et al., Aiming Higher: Results from a State Scorecard on
Health System Performance, 2009, The Commonwealth Fund, Oct. 2009.
19
Extra As Needed
20
Affordable Care Act: New Era of Health Reforms
Coherent Multi-payer Action Will Be Essential to
Stimulate and Support Improved Care Systems &
Bend the Cost Curve While Improving Value
21
U.S. Spends the Most: International Comparison of
Spending on Health, 1980–2007
8000
7000
6000
5000
Average spending on health
per capita ($US PPP)
16
United
it d States
St t
Switzerland
Canada
Netherlands
France
Germany
Australia
United Kingdom
14
12
10
4000
8
3000
6
2000
4
1000
2
0
1980
1985
1990
1995
Total expenditures on health
as percent of GDP
2000
2005
0
1980
United States
France
Switzerland
Germany
Canada
Netherlands
Australia
United Kingdom
1985
Data: OECD Health Data 2009 (November 2009).
Source: Commonwealth Fund Why Not the Best? U.S. National Scorecard, 2008. Updated.
1990
1995
2000
2005
22
Mortality Amenable to Health Care
U.S. Fails to Keep Pace
Pace—Now
Now Last out of 19 Countries
Deaths per 100,000 population *
1997/98
150
2002/03
130
109
99
100
76
81
88
84
89
65
71
74
74
77
93
96
106
115
113
88
50
71
115
128
97
97
89
116
134
80
82
82
84
84
90
101
103
103
104
Ita
l
Ca y
na
da
No
Ne rw
a
th
er y
la
nd
Sw s
ed
en
G
re
ec
e
Au
st
ria
G
er
m
an
y
Fi
Ne nla
n
w
Ze d
al
an
d
D
Un
en
ite
m
a
d
Ki rk
ng
do
m
Ire
la
n
Po d
Un rtu
ite ga
l
d
St
at
es
Fr
an
ce
Ja
p
Au an
st
ra
lia
Sp
ai
n
0
* Countries’ age-standardized death rates before age 75; from conditions where timely effective care can make a
difference. Includes: Diabetes, asthma, ischemic heart disease, stroke, infections screenable cancer.
Data: E. Nolte and C. M. McKee, “Measuring the Health of Nations,” Health Affairs, Jan/Feb 2008).
Source: The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results
from the National Scorecard on U.S. Health System Performance, 2008, The Commonwealth Fund, July 2008.
110
23
U.S. Chronically Ill Patient Experiences:
Access Coordination & Safety,
Access,
Safety 2008
Base: Adults with any chronic condition
Percent reported in
past 2 years:
AUS
CAN
FR
GER
NETH
NZ
UK
US
Access problem due
to cost*
36
25
23
26
7
31
13
54
Coordination
problem**
23
25
22
26
14
21
20
34
Medical, medication,
Medical
medication
or lab error***
29
29
18
19
17
25
20
34
* Due to cost, respondent did NOT: fill Rx or skipped doses, visit a doctor when had a medical problem, and/or get
recommended test, treatment, or follow-up.
** Test results/records not available at time of appointment and/or doctors ordered test that had already been done.
*** Wrong medication or dose, medical mistake in treatment, incorrect diagnostic/lab test results, and/or delays in
abnormal test results.
Data: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults
Source: C. Schoen et al., “In Chronic Condition: Experiences of Patients with Complex Healthcare Needs in Eight
Countries, 2008”, Health Affairs Web Exclusive, November 13, 2008.
24
Hospital Readmissions as Care System Indicator
Percent
Best State
Top 5 States Avg
All States Median
Bottom 5 States Avg
Worst State
30
25
22
27
23
21
18
15
13
14
13
15
0
Medicare patients readmitted to hospital within
30 days
Nursing Home: Discharged to NH, back within
30 days
DATA: Medicare readmissions—2006–07 Medicare 5% SAF Data for 31 initial admissions;
Nursing home admission and readmissions—2006 Medicare enrollment records and MEDPAR file
SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009