Figure 1. Annual Increases in Physician Fees and
SGR-Related Expenditures Per Fee-for-Service Beneficiary,
1998-2005
Fees
SGR-related expenditures per fee-for-service beneficiary
12
10.8
Percent change
10
9.3
5.9
6
2
8.2
7.7
8
4
10.0
4.9
3.8
2.1
4.5
4.0
2.2
1.4
0.1
0
-0.6
-2
-4
-6
-3.8
1998
1999
2000
2001
2002
2003
2004
Year
Source: Letter to Glenn M. Hackbarth, Chair, Medicare Payment Advisory Commission, from Herb B. Kuhn,
Director, Center for Medicare Management, Centers for Medicare and Medicaid Services, dated April 7, 2006.
2005
THE
COMMONWEALTH
FUND
Figure 2. Annual Rates of Increase in Physician Fees and
SGR-Related Expenditures Per Fee-for-Service Beneficiary,
1997-2001 and 2001-2005
Fees
SGR-related expenditures per fee-for-service beneficiary
7.4
Annual Percent Change
8
7.4
7
6
5
4
3.4
3
2
1
0
-1
-2
-0.7
1997-2001
2001-2005
Period
Source: Letter to Glenn M. Hackbarth, Chair, Medicare Payment Advisory Commission, from Herb B. Kuhn,
Director, Center for Medicare Management, Centers for Medicare and Medicaid Services, dated April 7, 2006.
THE
COMMONWEALTH
FUND
Figure 3. Medicare Part B Premium (Monthly),
1998-2006 (Actual) and 2007-2015 (Projected)
Part B Premium
140
122.40
120
88.50
100
80
60
43.80
40
20
20
15
20
14
20
13
20
12
20
11
20
10
20
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
0
Year
Source: Board of Trustees, Federal HI and Federal SMI Trust Funds, 2006 Annual Report.
THE
COMMONWEALTH
FUND
Figure 4. Profile of Medicare Elderly Beneficiaries
and Employer Coverage Nonelderly,
by Poverty and Health Status, 2003
No health problems,
higher income
15%
Health problems,
lower income
7%
Health problems,
lower income
38%
No health problems,
lower income
8%
Health problems,
higher income
24%
Health problems,
higher income
40%
Medicare, Ages 65+
No health problems,
higher income
56%
No health problems,
lower income
14%
Employer, Ages 19–64
Note: Respondents with undesignated poverty were not included; lower income defined as <200% of poverty; health
problems defined as fair or poor health, any chronic condition (cancer, diabetes, heart attack/disease, and arthritis),
or disability .
Source: The Commonwealth Fund Biennial Health Insurance Survey (2003).
THE
COMMONWEALTH
FUND
Figure 5. Projected Out-of-Pocket Spending As a Share of
Income Among Groups of Medicare Beneficiaries,
2000 and 2005
Out-of-pocket spending as percent of income
2000
80
2025
71.8
63.3
60
51.6
44.0
40
21.7
29.9
41.1
29.1
20
8.9 7.8
0
Beneficiaries age 65+
Beneficiairies with Disabled beneficiaries
physicial or cognitive
ages 45–65
health problems and
no other health
insurance
Beneficiaries ages
65–74 with high
incomes*
Female beneficiaries
age 85+ with physical
or cognitive health
problems and low
incomes^
* Annual household incomes of $50,000 or more.
^ Annual household incomes of $5,000 to $20,000.
Source: S. Maxwell, M. Moon, and M. Segal, Growth in Medicare and Out-of-Pocket Spending: Impact on Vulnerable
Beneficiaries, The Commonwealth Fund, January 2001 as reported in R. Friedland and L. Summer, Demography Is
Not Destiny, Revisited, The Commonwealth Fund, March 2005.
THE
COMMONWEALTH
FUND
Figure 6. Access to Physicians for Medicare
Beneficiaries and Privately Insured People, 2005
Medicare
Percent
100
90
80
70
60
50
40
30
20
10
0
74
83
67
Routine Care
Privately Insured
89 86
75
Illness or
Injury
Never had a delay to
appointment
75 75
Primary care
Specialist
No problem finding
physician
THE
COMMONWEALTH
FUND
Source: MedPAC Report to the Congress: Medicare Payment Policy, March 2006, p. 85.
Figure 7. Proportion of Recommended Care
Received by U.S. Adults, by Selected Conditions
Percent of recommended care received
100
76
80
60
55
65
54
39
40
23
20
0
Overall
Breast Cancer Hypertension
Asthma
Pneumonia
Hip Fracture
Source: McGlynn et al., “The Quality of Health Care Delivered to Adults in the United
States,” The New England Journal of Medicine (June 26, 2003): 2635–2645.
THE
COMMONWEALTH
FUND
Figure 8. Life Expectancy at Age 65
Female
25
21.3
16.9
20.6
19.6
20.0
17.6
17.2
an
C
18.0
21.0
us
A
20
23.0
Male
16.7
19.6
19.5
16.0
16.1
19.1
16.6
16.1
15
10
5
0
d
te
ni
U
d
te
ni
U
2)
2
00
(2
00
(2
om
s
te
ta
)
)
)
02
2
00
(2
1
00
(2
n
ia
0
(2
3)
)
02
gd
in
K
S
y
ed
M
0
(2
nd
la
ea
an
D
C
Z
m
er
G
E
O
ew
N
a
ad
)
01
)
00
(2
0
(2
3
00
(2
ia
al
tr
n
ce
an
Fr
pa
Ja
)
THE
COMMONWEALTH
FUND
Source: OECD Health Data, 2005.
Figure 9. Patient Reported Medical Mistake,
Medication Error, or Test Error in Past 2 Years
Percent
50
34
27
30
23
25
25
22
0
AUS
CAN
GER
NZ
Source: 2005 Commonwealth Fund International Health Policy Survey.
UK
US
THE
COMMONWEALTH
FUND
Figure 10. Interpersonal Quality of Care Is Lacking
Percent of community-dwelling adults
in 2001 who visited doctor's office in past year
Ages 45–64
100
80
60
56
65
59
59
Age 65+
59
66
46
54
40
20
0
Health providers
Health providers
Health providers
Health providers
always listened
always explained
always showed
always spent
carefully
things clearly
respect
enough time
Source: S. Leatherman and D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A
Chartbook, 2005, The Commonwealth Fund. www.cmwf.org; Medical Expenditure Panel Survey
(AHRQ 2005).
THE
COMMONWEALTH
FUND
Figure 11. Communication With Physicians
Views of Sicker Adults
In the past 2 years:
AUS
CAN
NZ
UK
US
Left a doctor’s
office without
getting important
questions answered
21
25
20
19
31
Did not follow a
doctor’s advice
31
31
27
21
39
THE
COMMONWEALTH
FUND
Source: 2002 Commonwealth Fund International Health Policy Survey.
Figure 12. Deficiencies in Care Coordination
Percent saying in the
past 2 years:
AUS CAN GER
NZ
UK
US
Test results or records
not available at time of
appointment
12
19
11
16
16
23
Duplicate tests: doctor
ordered test that had
already been done
11
10
20
9
6
18
Percent who
experienced either
coordination problem
19
24
26
21
19
33
Source: 2005 Commonwealth Fund International Health Policy Survey.
Adults with Health Problems.
THE
COMMONWEALTH
FUND
Figure 13. Continuity of Care with Same Physician
Percent:
AUS
CAN
GER
NZ
UK
US
Has regular doctor
92
92
97
94
96
84
--5 years or more
56
60
76
57
66
42
No regular doctor
8
8
3
6
4
16
THE
COMMONWEALTH
FUND
Source: 2005 Commonwealth Fund International Health Policy Survey.
Adults with Health Problems.
Percent
Figure 14. Coordination Problems by
Number of Doctors
75
1 Doctor
4 or more Doctors
50
43
31
27
25
15
30
16
7
26
22
23
30
11
0
AUS
CAN
NZ
UK
US
GER
*Either records/results did not reach doctors office in time for appointment or doctors ordered a
duplicate medical test
Source: C. Schoen et al., “Taking the Pulse: Experiences of Patients with Health Problems in Six
Countries,” Health Affairs Web Exclusive (November 3, 2005). Based on the 2005 Commonwealth
Fund International Health Policy Survey.
THE
COMMONWEALTH
FUND
Figure 15. Two-Thirds of Medicare Spending is for
People With Five or More Chronic Conditions
No chronic
conditions
1%
1-2 chronic
conditions
10%
5+ chronic
conditions
66%
3 chronic
conditions
10%
4 chronic
conditions
13%
Source: G. Anderson and J. Horvath, Chronic Conditions: Making the Case for Ongoing Care (Baltimore,
MD: Partnership for Solutions, December 2002)
THE
COMMONWEALTH
FUND
Figure 16. Physician Use of Electronic Technology
Varies by Application
Percent indicating "routine” or “occasional" use
1 Physician
87%
85% 84%
79%
All Physicians
2-9 Physicians
77%
68%
10-49 Physicians
66%
59%
50+ Physicians
61%
57%
46%
37%
36%
27%
25%
35%
27%
13%
14%
Electronic billing
Access to test
Ordering*
23%
Electronic medical
results
records
* Electronic ordering of tests, procedures, or drugs.
Source: Commonwealth Fund 2003 National Survey of Physicians and Quality of Care.
THE
COMMONWEALTH
FUND
Figure 17. Electronic Health Records (EHR) in
Solo or Small Group Practices: A Case Study
EHR Financial Costs Per FTE Provider For 14 Practices,
2004-2005
Dollars
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
Initial costs
Ongoing costs per provider per year
63,600
43,826
8,412
Average per FTE
provider
14,462
5,957
Minimum
11,867
Maximum
Source: R. Miller, et al. “The Value of Electronic Health Records in Solo or Small Group
Practices. Health Affairs. 24(5). (September/October 2005): 1127.
THE
COMMONWEALTH
FUND
Figure 18. EHR Financial Benefits Per FTE Provider,
For 14 Solo/Small Group Practices, 2004-2005
Average per FTE
provider ($)
35,000
32,737
30,000
25,000
20,000
16,929
15,808
Savings from
increased coding
levels
Efficiency
savings
15,000
10,000
5,000
0
Total benefits
per provider
Source: R. Miller, et al. “The Value of Electronic Health Records in Solo or Small Group
Practices. Health Affairs. 24(5). (September/October 2005): 1127.
THE
COMMONWEALTH
FUND
Figure 19. Variation in Per Capita Medicare Spending by
Hospital Referral Region, 2000
THE
COMMONWEALTH
FUND
Source: Eliot Fisher, presentation at AcademyHealth Annual Research Meeting, June 2006.
Figure 20. Variation in Annual Total Cost and
Quality for Chronic Disease Patients
Quality of Care* and Medicare Spending for Beneficiaries with
Three Chronic Conditions, by Hospital Referral Region
Best Practice Curve
1.60
1.40
A
Average Quality of Care Score
Greenville, NC
Ft. Lauderdale, FL
East Long Island, NY
Orange County, CA
Manhattan, NY
1.20
1.00
Boston, MA
0.80
0.60
0.40
B
Saginaw, MI
D
Newark, NJ
C
Melrose Park, IL
Median Amount Spent per Patient
per HRR = $28,694
0.20
0.00
$-
$10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000
Average Annual Reimbursement per Beneficiary (Wage-Index Adjusted)
* Based on percent of beneficiaries with three conditions (diabetes, chronic obstructive pulmonary disease, and
congestive heart failure) who had a doctor’s visit four weeks after hospitalization, a doctor’s visit every six months,
annual cholesterol test, annual flu shot, annual eye exam, annual HbA1C test, and annual nephrology test.
Source: G. Anderson and R. Herbert for The Commonwealth Fund, Medicare Standard Analytical File 5% 2001 data .
THE
COMMONWEALTH
FUND
Figure 21. Medicare Spending Per Enrollee and
Mortality Rate by State, 2003
Mortality Rate of Medicare Enrollees
Medicare Spending per Enrollee
$4,500
$5,500
$6,500
$7,500
$8,500
2.5%
HI
3.5%
4.5%
5.5%
MN
OR
CO
AK
UT
ID WY
NH AZ DC
DE
NV FLMD CA
NM WI VT
NY
IA SD MTWA VA IN SCKS
US
MI TX
ND
CT
NE ME
MA
NC WV KY OH IL
GA
AR
MS
MO
AL
PA
LA
TN OK
RI
NJ
6.5%
Source: Data from The Dartmouth Atlas of Health Care, www.dartmouthatlas.org
THE
COMMONWEALTH
FUND
Figure 22. IHA Trends in Point-of-Care Technology
Percent
70
2003 measurement year
2004 measurement year
60
50
40
30
20
10
0
Electronic
Electronic
Electronic
Electronic
Electronic
prescribing check of Rx retrieval of
access of
retrieval of
interaction
clinical
patient
notes
reminders
lab results
Source: Tom Williams, “California Pay for Performance (P4P): A Case Study.”
THE
COMMONWEALTH
FUND
Figure 23. Evaluation of PacifiCare
Pay for Performance: Improvement in
Cervical Cancer Screening
Percent improvement in cervical cancer screening rates among
physician groups
20
15
10
5.3
5
1.7
0
California
(Intervention group)
Pacific Northwest
(Control group)
Source: M.B. Rosenthal et al., “Early Experience with Pay-for-Performance: From Concept to
Practice,” JAMA 294, no. 14 (October 12, 2005): 1788-93.
THE
COMMONWEALTH
FUND
Figure 24. Physicians Participating in the
Diabetic Care Program From 1997 to 2003
Showed Significant Improvement in Performance
Percent of patients reaching quality target
100
46
50
25
45
17
0
1997
2003
HgA1c < 7%
1997
2003
LDL/Chol < 100mg/dL
THE
COMMONWEALTH
FUND
Source: National Committee for Quality Assurance web site, www.ncqa.org/dprp.
Figure 25. Medicare Premier Hospital Demonstration:
Higher Quality Hospitals Have Fewer Readmissions
Readmission Rates by Pneumonia Quality Ranking (Percent)
20
15.4
15
14.8
13.6
13.1
51–75%
76–90%
11.6
10
5
0
Bottom
26–50%
Top quality
quality
decile
quartile
© 2005 Premier, Inc.
Source: Stephanie Alexander, “CMS/Premier Hospital Quality Incentive Demonstration Project:1st Year Results,”
Presentation at IOM P4P Subcommittee Meeting, November 30, 2005
THE
COMMONWEALTH
FUND
Figure 26. Coordination Across Sites of Care:
Care Transition Measure Scores,* Emergency
Department Use, and Hospital Readmissions
100
90
Emergency Department
Use
80
p=0.01
80
100
90
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
No
Yes
Hospital Readmissions
p=0.04
No
Yes
* When I left the hospital, I had a good understanding of the things I was responsible for in
managing my health; when I left the hospital, I clearly understood the purpose for taking each
of my medications; The hospital staff took my preferences and those of my family or caregiver
into account in deciding what my health care needs would be when I left the hospital.
Source: E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The Commonwealth
Fund Commission on a High Performance Health System, March 30, 2006.
THE
COMMONWEALTH
FUND
Figure 27. Improving Care Coordination and
Reducing Cost
Effect of Advanced Practice
Nurse Care on Congestive Heart
Failure Patients’ Average Per
Capita Expenditures
Dollars
$12,000
$10,000
Visits
$9,618
$8,000
$6,000
$4,000
Inpatient Care
$6,152
$8,809
$4,977
$2,000
$0
$809
$1,175
Control
Intervention
• Importance of improving
transitions in care,
doctor to doctor, and
post-hospital
• Follow-up care following
hospital discharge could
reduce rehospitalization
• High cost care
management could
reduce errors and lower
costs
• Will require restructuring
Medicare benefits and
incentives
THE
COMMONWEALTH
FUND
Source: M.D. Naylor, Making the Bridge from Hospital to Home, The Commonwealth Fund, Fall 2003.
Figure 28. Improvement in Doctors’ Cervical Cancer
Screening Rates Compared to Bonus Payments
After Implementation of Quality Incentive Program
Improvement in
Screening Rates
Bonuses Received
Percent
Thousands of dollars
25
500
20
400
15
11.1
7.4
10
5
437
300
200
2.5
128
100
0
27
0
High
Middle
Low
performing performing performing
group
group
group
High
Middle
Low
performing
performing
performing
group
group
group
Source: M.B. Rosenthal et al., “Early Experience with Pay-for-Performance: From Concept to
Practice,” JAMA 294, no. 14 (October 7, 2004): 1788-93.
THE
COMMONWEALTH
FUND
Figure 29. Most Physicians Have Not Been Involved in
Collaborative Efforts to Improve Quality of Care
Percent indicating involvement in any collaborative efforts in past two years*
No, have not been involved
Yes, a REGIONAL effort
100
Yes, a LOCAL effort
Yes, a NATIONAL effort
67
Involved in at least one effort (32%)
50
23
8
6
0
* Multiple answers possible.
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
THE
COMMONWEALTH
FUND
Figure 30. Current Factors Affecting
Physicians’ Compensation
Major Factor
Minor Factor
Not a Factor
58%
Productivity/ Billing
14%
27%
72%
Board Re-Certification Status
11%
28%
60%
39%
Measures of Clinical Care
8%
19%
72%
27%
Patient Surveys/ Experience
Quality Bonus/Incentive Payments from
Insurance Plans
8%
19%
27%
4% 15%
72%
80%
19%
THE
COMMONWEALTH
FUND
Source: The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care.