Exhibit ES-1. Net Impact of Path Recommendations on National Health
Expenditures Compared with Current Projection, 2010–2020 (in billions)
Total NHE
Private
Employers
State & Local
Governments
Households
Federal
Budget
–$1,010
–$170
–$10
–$82
–$749
Enhanced payment for primary care
–$71
–$28
–$2
–$11
–$30
Encouraged adoption of Medical
Home model
–$175
–$25
–$13
–$36
–$101
Bundled payment for acute care
episodes
–$301
–$75
–$4
–$11
–$211
• High-cost area updates
–$223
–$64
–$3
–$29
–$127
• Prescription drugs
–$76
+$22
+$12
+$5
–$115
• Medicare Advantage
–$165
$0
$0
$0
–$165
Total Payment Reforms
Correcting price signals
Data: Estimates by The Lewin Group for The Commonwealth Fund.
Source: The Lewin Group, The Path to a High Performance U.S. Health System: Technical Documentation
(Washington, D.C.: The Lewin Group, 2009).
THE
COMMONWEALTH
FUND
Exhibit ES-2. Total National Health Expenditure Growth for Hospitals
and Physicians, Current Projections and with Policy Changes, 2009–2020
Hospital Expenditures (trillions)
Physician Expenditures (trillions)
$1.8
$1.8
Current Projection
$1.6
Path Policy
Current Projection
Path Policy
$1.6 $1.6
$1.4
$1.4
$1.4
$1.3
$1.2
$1.2
$1.0
$1.0
$1.1
$0.8
$0.8
$0.8
$0.6
$0.6
$0.4
$0.4
$0.2
$0.2
$0.0
$0.7
$0.0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Data: Estimates by The Lewin Group for The Commonwealth Fund.
Source: The Lewin Group, The Path to a High Performance U.S. Health System: Technical Documentation
(Washington, D.C.: The Lewin Group, 2009).
THE
COMMONWEALTH
FUND
Integrated
system
capitation
Global DRG
fee: hospital,
post- acute,
and physician
inpatient
Outcome
measures;
large % of
total payment
Less
Feasible
Care coordination
and intermediate
outcome
measures;
moderate % of
total payment
Global DRG fee:
hospital only
Global
ambulatory
care fees
More
Feasible
Global primary
care fees
Preventive care;
management of
chronic conditions
measures; small %
of total payment
Blended FFS
and medical
home fees
Continuum of P4P Design
Continuum of Payment Bundling
Exhibit 1. Interrelation of Organization and Payment
FFS and DRGs
Small MD
practice;
unrelated
hospitals
Primary care
MD group
practice
Multispecialty
MD group
practice
Hospital
system
Integrated
delivery
system
Source: A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, Organizing the U.S. Health
Care Delivery System for High Performance (New York: The Commonwealth Fund, Aug. 2008).
THE
COMMONWEALTH
FUND
Exhibit 2. If Insurer Premium Trend Continues, Public Health
Insurance Plan Enrollment Will Grow: Distribution of Coverage by
Primary Source Under Current Law (2010) and Path Framework
(Small Firms in 2010, All Firms in 2014)
Path Framework,
Small Firms (2010)
Current Law (2010)
Path Framework,
All Firms (2014)
Uninsured
4m
1%
Uninsured
4m
1%
Medicaid
49m
16%
Medicare
41m
13%
Private
170m
55%
Uninsured
49m
16%
Medicaid
42m
14%
Medicaid
49m
16%
Private
178m
58%
Medicare
41m
13%
Private
109m
35%
Medicare
39m
13%
Public Health Insurance Plan
43m
14%
Public Health Insurance Plan
105m
34%
THE
Source: The Lewin Group, The Path to a High Performance U.S. Health System: Technical Documentation
(Washington, D.C.: The Lewin Group, 2009).
COMMONWEALTH
FUND
Exhibit 3. Adults with an Accessible Primary Care Provider
Percent of adults ages 19–64 with an accessible primary care provider*
U.S. Average
66
2002
65
2005
U.S. Variation 2005
69
White
59
Black
49
Hispanic
73
400% + of poverty
200–399% of poverty
63
53
<200% of poverty
74
Insured all year
51
Uninsured part year
37
Uninsured all year
0
20
40
60
* An accessible primary care provider is defined as a usual source of care who provides preventive care,
care for new and ongoing health problems, and referrals, and who is easy to get to.
Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
80
100
THE
COMMONWEALTH
FUND
Exhibit 4. Receipt of Recommended Screening and
Preventive Care for Adults
Percent of adults (ages 18+) who received all recommended screening
and preventive care within a specific time frame given their age and sex*
U.S. Average
49
2002
50
2005
U.S. Variation 2005
58
400% + of poverty
200–399% of poverty
47
39
<200% of poverty
53
Insured all year
46
Uninsured part year
32
Uninsured all year
0
20
40
60
* Recommended care includes seven key screening and preventive services: blood pressure,
cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.
Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
80
100
THE
COMMONWEALTH
FUND
Exhibit 5. Chronic Disease Under Control: Diabetes and Hypertension
National Average
By Insurance, 1999–2004
Percent
Percent
1999–2000
100
2003–2004
Insured
100
Uninsured
88
80
81
79
80
63
60
60
41
41
40
40
31
21
20
20
0
0
Diabetes under control*
High blood pressure
under control**
Diabetes under
control*
* Refers to diabetic adults whose HbA1c is <9.0.
** Refers to hypertensive adults whose blood pressure is <140/90 mmHg.
Data: J. McWilliams, Harvard University analysis of National Health and Nutrition Examination Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
High blood pressure
under control**
THE
COMMONWEALTH
FUND
Exhibit 6. Costs of Care for Medicare Beneficiaries with
Multiple Chronic Conditions, by Hospital Referral Regions, 2001 and 2005
Ratio of
percentile groups
Average annual reimbursement
Average
10th
percentile
25th
percentile
75th
percentile
90th
percentile
90th to
10th
75th to
25th
2001
2005
$31,792
$38,004
$20,960
$25,732
$23,973
$29,936
$37,879
$44,216
$43,973
$53,019
2.10
2.06
1.58
1.48
2001
2005
$18,461
$23,056
$12,747
$16,144
$14,355
$18,649
$20,592
$26,035
$27,310
$32,199
2.14
1.99
1.43
1.40
2001
2005
$13,188
$15,367
$8,872
$11,317
$10,304
$12,665
$15,246
$17,180
$18,024
$20,062
2.03
1.77
1.48
1.36
2001
2004
$22,415
$27,498
$15,355
$19,787
$17,312
$22,044
$25,023
$31,709
$32,732
$37,450
2.13
1.89
1.45
1.44
All 3 conditions
(Diabetes + CHF + COPD)
Diabetes + CHF
Diabetes + COPD
CHF + COPD
CHF = Congestive heart failure; COPD = Chronic obstructive pulmonary disease.
Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare
Standard Analytical Files (SAF) 5% Inpatient Data.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
THE
COMMONWEALTH
FUND
Exhibit 7. Medicare Reimbursement and 30-Day Readmissions by State
THE
COMMONWEALTH
FUND
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
Exhibit 8. Medicare Hospital 30-Day Readmission Rates
Percent of Medicare beneficiaries admitted for one of 31 select conditions
who are readmitted within 30 days following discharge*
30
20
18
21
20
18
16
20
75th
90th
16
15
14
19
10
0
2003
2005
U.S. Mean
10th
25th
75th
90th
Hospital Percentiles,
2005
10th
25th
State Percentiles,
2005
* See report Appendix B for list of conditions used in the analysis.
Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard
Analytical Files (SAF) 5% Inpatient Data.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
THE
COMMONWEALTH
FUND
Exhibit 9. Average Risk-Adjusted Standardized Spending
for Hospital Readmissions and Post-Acute Care
After Coronary Artery Bypass, 2001–2003
Bottom 25th Percentile
Average Spending (Mean)
Upper 75th Percentile
$3,500
$2,911
$3,000
$2,822
$2,500
$1,887
$2,000
$1,651
$1,500
$1,000
$947
$800
$500
$0
Hospital Readmissions
Post-Acute Care
Source: G. Hackbarth, R. Reischauer, and A. Mutti, “Collective Accountability for Medical Care—
Toward Bundled Medicare Payments,” New England Journal of Medicine, July 3, 2008 359(1):3–5.
THE
COMMONWEALTH
FUND
Exhibit 10. Net Impact of Path Recommendations on National Health
Expenditures Compared with Current Projection, 2010–2020 (in billions)
Total NHE
Private
Employers
State & Local
Governments
Households
Federal
Budget
–$1,010
–$170
–$10
–$82
–$749
Enhanced payment for primary care
–$71
–$28
–$2
–$11
–$30
Encouraged adoption of Medical
Home model
–$175
–$25
–$13
–$36
–$101
Bundled payment for acute care
episodes
–$301
–$75
–$4
–$11
–$211
• High-cost area updates
–$223
–$64
–$3
–$29
–$127
• Prescription drugs
–$76
+$22
+$12
+$5
–$115
• Medicare Advantage
–$165
$0
$0
$0
–$165
Total Payment Reforms
Correcting price signals
Data: Estimates by The Lewin Group for The Commonwealth Fund.
Source: The Lewin Group, The Path to a High Performance U.S. Health System: Technical Documentation
(Washington, D.C.: The Lewin Group, 2009).
THE
COMMONWEALTH
FUND
Exhibit 11. Total National Health Expenditures (NHE), 2009–2020
Current Projection and Alternative Scenarios
NHE in trillions
$6
Current projection
6.7% annual
growth
Reform proposals
$5
$5.2
Constant (2009) proportion of GDP
$4.6
$4.2
$4
5.5% annual
growth
$3
4.7% annual
growth
$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 Commonwealth Fund Commission on a High Performance Health System,
The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way
(New York: The Commonwealth Fund, Feb. 2009).
THE
COMMONWEALTH
FUND
Exhibit 12. Total National Health Expenditure (NHE) Growth by
Provider Group, Current Projections and with Policy Changes, 2009–2020
Total NHE
All other
Physician & other professional
Hospital
Projected Growth, Current Policy
Revenue Growth with Path Policies
Expenditure (trillions)
Expenditure (trillions)
$6.0
$6.0
$5.2
$5.0
$5.0
$2.3
$4.0
$4.6
$4.0
$2.1
$3.0
$2.0
$2.5
$1.0
$3.0
$1.3
$2.0
$0.7
$1.0
$1.6
$0.8
$0.0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
$1.0
$2.5
$1.0
$1.1
$0.7
$1.4
$0.8
$0.0
2009
2010
2011
2012
2013
2014
Data: Estimates by The Lewin Group for The Commonwealth Fund.
Source: The Commonwealth Fund Commission on a High Performance Health System,
The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way
(New York: The Commonwealth Fund, Feb. 2009).
2015
2016
2017
2018
2019
2020
THE
COMMONWEALTH
FUND
Exhibit 13. Total National Health Expenditure Growth for Hospitals
and Physicians, Current Projections and with Policy Changes, 2009–2020
Hospital Expenditures (trillions)
Physician Expenditures (trillions)
$1.8
$1.8
Current Projection
$1.6
Path Policy
Current Projection
Path Policy
$1.6 $1.6
$1.4
$1.4
$1.4
$1.3
$1.2
$1.2
$1.0
$1.0
$1.1
$0.8
$0.8
$0.8
$0.6
$0.6
$0.4
$0.4
$0.2
$0.2
$0.0
$0.7
$0.0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Data: Estimates by The Lewin Group for The Commonwealth Fund.
Source: The Lewin Group, The Path to a High Performance U.S. Health System: Technical Documentation
(Washington, D.C.: The Lewin Group, 2009).
THE
COMMONWEALTH
FUND
Exhibit 14. Provider Payments as a Percent of Medicare Payments
for Similar Services
160%
141%
140%
123%
120%
94%
100%
80%
69%
60%
40%
20%
0%
Private Insurance
Medicaid
Hospital Care
Private Insurance
Medicaid
Physician Care
Data: American Hospital Association, MedPAC, Kaiser Family Foundation.
Source: The Lewin Group, The Path to a High Performance U.S. Health System: Technical Documentation
(Washington, D.C.: The Lewin Group, 2009).
THE
COMMONWEALTH
FUND
Exhibit 15. Expenditures for Health Services by Type of Service
and Source of Funds, 2007 (billions)
Out-of-pocket
$23b
3%
Medicaid
$120b
17%
Medicaid
$33b
7%
Other
public
$68b
10%
Private
$257b
37%
Medicare
$196b
28%
Hospital Care
Total: $697b
Out-of-pocket
$50b
10%
Other
public
$32b
7%
Medicare
$96b
20%
Private
$237b
49%
Physician and Clinical Services
Total: $479b
Source: M. Hartman, A. Martin, P. McDonnell et al., “National Health Spending in 2007: Slower Drug Spending
Contributes to Lowest Rate of Overall Growth Since 1998,” Health Affairs, Jan./Feb. 2009 28(1):246–61.
THE
COMMONWEALTH
FUND