A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency

1. A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency Karen Davis President, The Commonwealth Fund National Association of Community Health Centers Plenary Address March 27, 2006 kd@cmwf.org www.cmwf.org

2. Need for Better Access, Higher Quality, and Greater Efficiency • The U.S. health system fails to provide access to care for all • 46 million uninsured • 16 million adults underinsured • The U.S. health system fails to reliably deliver high quality care to all • Only 55 percent of recommended care delivered • Only half of adults received recommended preventive care • One-third of sicker adults report medical, medication, or lab test error in past two years • The U.S. health system is costlier than any other country, but fails to deliver superior value for money spent

3. Ten Keys to Transforming the U.S. Health Care System • Agree on shared values and goals • Organize care and information around the patient • Expand the use of information technology • Enhance the quality and value of care • Reward performance • Simplify and standardize • Expand health insurance and make coverage automatic • Guarantee affordability • Share responsibility for health care financing • Encourage collaboration

4. Community Health CentersCan Lead the Way Within own organizations • Organize care and information around the patient • Expand the use of information technology • Enhance the quality and value of care By joining with others for policy change • Support Medicaid, CHIP, and Medicare • Expand health insurance and make coverage automatic and affordable • Embrace change – transparency, public reporting, pay for performance

5. Community Health Centers:Key Role in Caring for Most Vulnerable

6. Health Center Patients Are Predominantly Low-Income, and Most are Uninsured or Have Medicaid Patients by Poverty Level Patients by Insurance Status Over 200% poverty 10% Private 15% Uninsured 39% Other public 3% 151–200% poverty 6% Medicare 7%% 101–150% poverty 14% 100% poverty and below 69% Medicaid/ SCHIP 36% Source: Bureau of Primary Health Care, 2003 Uniform Data System

7. Racial and Ethnic Minorities Make Up Two-Thirds of all Health Center Patients Source: Bureau of Primary Health Care, 2002 Uniform Data System

8. Nearly One-Third of Health Center Patients Prefer Languages Other than English Percent of users preferring languages other than English Source: 1997-2002 Uniform Data System, BPHC, HRSA, DHHS.

9. Proportion of Vulnerable Populations at Health Centers and in the U.S. * Most recent year available. # For a family of three, $15,260 annual income in 2003 and %15,670 for in 2004. Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC Report, August 2005.

10. Growth in Health Center Patients by Insurance Status, 1999-2004 In millions Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC Report, August 2005.

11. Community Health Centers:A Leader in High Performance Care

12. Health Center Patients 25% delayed care due to costs 16% went without needed care 12% could not fill Rx Non-Health Center Patients 55% delayed care due to costs 30% went without needed care 24% could not fill Rx Increased Access of Uninsured to Care Source: Politzer, R., et al. 2001. “Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care.” Medical Care Research and Review 58(2):234-248.

13. Ambulatory Care Sensitive Events by Regular Source of Care Number of ACS events per 100 persons Source: M. Falik et al., “Comparative Effectiveness of Health Centers as Regular Source of Care,” Journal of Ambulatory Care Management 29, no. 1 (November 26, 2005): 24-35.

14. Pap Tests by Race:Women Served by Community Health Centers Compared to National Sample Source: Dan Hawkins, “Improving Minority Health and Reducing Disparities through the Health Disparities Collaboratives of America’s Community Health Centers,” Presentation to NAPH (June 24, 2005) Santa Fe, NM.

15. Self-Reported Quality Assessment of Care Received at Health Centers Percent Source: PEERS Report, NACHC analysis of PEERS, 1993-2001

16. Wait Times at Health Centers, 1993–2001 Percent of health center patients Source: PEERS Report, NACHC analysis of PEERS, 1993-2001

17. Community Health Centers:Assuming a Leadership Role in A High Performance Health System

18. Actions Community Health Centers Can Take to Promote High Performance • Organizing care and information around the patient • Patient-centered care • Medical home or advanced primary care practice • Advanced access • Information technology • Enhancing the quality and value of care • Chronic disease management • Coordination of care

19. Attributes of Patient-Centered Primary Care • Superb access to care • Quick appointments, short waiting times, accessible off-hours coverage, e-mail and telephone consultations • Patient engagement in care • Information for patients on treatment and self-management plans, preventive and follow-up care reminders, access to medical records, assistance with self-care • Clinical information systems • Patient registries; monitor adherence to treatment; lab and test results; decision support • Care coordination • Coordination of specialist care, systems/processes to prevent errors in transitions, post-hospital follow-up • Integrated and comprehensive team care • Excellent communication among physicians, nurses, and other health professionals, and appropriate use of skills of all team members • Routine patient feedback to doctors • Learn from patient-surveys and feedback • Publicly available information • Patients have accurate, timely, complete information on physicians and other clinicians providing care

20. Insurance Status and Continuity of Care with a Regular Doctor Same doctor for more than 5 years 18% No regular doctor 54% No regular doctor 19% Same doctor for more than 5 years 34% Same doctor for fewer than 5 years 28% Same doctor for fewer than 5 years 47% Uninsured adults (full or part year) Insured adults Source: Karen Davis, Stephen C. Schoenbaum, Karen Scott Collins, Katie Tenney, Dora L. Hughes, and Anne-Marie J. Audet, Room for Improvement, The Commonwealth Fund, April 2002.

21. People in Community Health Centers Who Have a Usual Source of Care, 2002 Percent Source: AHRQ, “Focus on Federally Supported Health Centers,” National Healthcare Disparities Report, 2004. http://www.qualitytools.ahrq.gov/disparitiesReport/browse/browse.aspx?id=4981

22. Minorities Without a Regular DoctorAre More Likely to Use Emergency Room for Care Percent reporting emergency room or no regular place of care Source: K.S. Collins et al., “Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans,” The Commonwealth Fund, March 2002

23. In U.S., Canada Adults Less Likely to Be Able to See Physician Same Day and More Likely to Substitute ER for Regular Physician Care Access to Doctor When Sick or Needed Medical Attention Percent AUS CAN NZ UK US AUS CAN NZ UK US Went to ER for condition that could have been treated by regular doctor if available Same day appointment Source: 2004 Commonwealth Fund International Health Policy Survey

24. Primary Care Development Corporation Primary Care Clinic Redesign Collaborative: Before Redesign 148 Minutes, 11 Steps WAITING ROOM NURSING STATION FRONT DESK CASHIER BATHROOM NURSING STATION EXAM ROOM WAITING ROOM FRONT DESK CLERK FRONT DESK LAB EXIT After Redesign 50 Minutes, 4 Steps EXAM ROOM WAITING ROOM FRONT DESK CASHIER EXIT Source: Pamela Gordon, M.A., and Matthew Chin, M.P.A., Achieving a New Standard in Primary Care for Low-Income Populations: Case Study 1: Redesigning the Patient Visit, The Commonwealth Fund, August 2004

25. The PCDC Track Record

26. Center for Shared Decision-Making Dartmouth-Hitchcock Medical Center • Provides tools to assist with health care decisions (e.g., videotapes, booklets, websites) • Provides follow-up counseling with skilled staff • Seeks to be a prototype for health care systems nationwide Kate Clay, BA, MSN, Program Director

27. Patient Access to Personal Health Records Percent 88 82 80 80 70 Source: The Commonwealth Fund 2004 International Health Policy Survey.

28. Electronic Access to Patient Test Results & Medical Records (EMRs), and Electronic Ordering, by Practice Size Percent who currently “routinely/occasionally” use the following * * Electronic ordering of tests, procedures, or drugs. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

29. E.Wagner, MD

30. Health Disparities Collaboratives • Goal: Implement in all 1,000 health centers by 2006 • 600 health centers nationwide participating • 250,000+ health center patients with chronic disease enrolled in electronic registries • Chronic Care Model: • Use of evidence-based care • Assure care continuity • Effectively involve patients in self-management • Completely re-design system to emphasize health • Collaboratives • Training and technical assistance • Quality Improvement infrastructure • Partnerships at the local, state, and national level • Commonwealth Fund co-funding evaluation with AHRQ – Bruce Landon Harvard

31. New York City Health and Hospitals Corporation:Diabetes Outcomes: HBA1c, Blood Pressure • Average A1C<7 increased from 30% to 42% • 31% with BP 130/80 at baseline, increased to 57% Source: Karen Scott-Collins, MD, MPH, Deputy Chief Medical Officer, Health Care Quality and Clinical Services, New York City Health and Hospitals Corporation

32. Physicians’ Participation in Redesign and Collaborative Activities, by Practice Size Percent indicating involvement in redesign and collaborative efforts Total 1 Physician 2–9 Physicians 10–49 Physicians 50+ Physicians Redesign Efforts Collaborative Efforts* * Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years. Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

33. Health Policy: Need for Leadership • Federal budget deficits harmful to U.S. economy in long-term • Tax revenues as percent of GDP at 40 year low, yet further tax cuts are on the table • Cuts to Medicaid have potential to harm access to health care for low-income beneficiaries; savings not used to expand coverage of uninsured • Medicare privatization contributes to higher, not lower, costs and budget outlays; no solution to Medicare long-term fiscal problems • Real solutions to grappling with nation’s health care problems not being considered

34. Tax Revenues at Lowest Percent of GDP in 40 Years Percent of GDP Actual Projected Average Outlays, 1962-2004 Average Revenues, 1962-2004 Note: Actual 1962–2004; Projected 2005–2015. Source: Congressional Budget Office, The Budget and Economic Outlook: Fiscal Years 2006 to 2015, January 2005.

35. Average Annual Medicaid Spending Growth Per Enrollee Lower Than Private Health Spending, 2000–2003 Percent average annual growth Source: J. Holahan and A. Ghosh, “Understanding the Recent Growth in Medicaid Spending, 2000–2003,” Health Affairs Web Exclusive, January 26, 2005; B.C. Strunk and P.B. Ginsburg, “Trends: Tracking Health Care Costs: Trends Turn Downward In 2003,” Health Affairs Web Exclusive, June 9, 2004; Kaiser/HRET, Employer Health Benefits 2003 Annual Survey, 2003

36. Higher Deductibles Associated with Greater Access Problems Percent of adults ages 21-64 who have delayed or avoided getting health care due to cost • Administration policy provides for: • Tax incentives for the purchase of high deductible health plans • Tax credits for low-income uninsured individuals and families • Minor effect on uninsured (e.g. 2-3 million out of 46 million uninsured) • Almost no effect on rising health care costs • Likely to increase “underinsurance” and pose barriers to care for low-income and chronically ill Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account. **Health problem defined as fair or poor health or one of eight chronic health conditions. Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

37. Percent of Adults Ages 18–64 Uninsuredby State 1999–2000 2003–2004 NH ME WA NH VT ME WA VT ND MT ND MT MN MN OR NY MA WI OR MA NY ID SD WI RI MI ID SD RI WY MI CT PA WY NJ CT IA PA NJ NE IA OH DE IN NE OH NV DE IN IL MD NV WV UT VA IL MD CO DC WV UT VA KS MO KY CA CO DC KS MO KY CA NC NC TN TN OK SC AR OK AZ NM SC AR AZ NM MS GA AL MS GA AL TX LA TX LA FL FL AK AK HI HI 24% or more 19%–23.9% 14%–18.9% Less than 14% Source: Two-year averages 1999–2000 and 2003–2004 from the Census Bureau’s March 2000, 2001 and 2004, 2005 Current Population Surveys. Estimates by the Employee Benefit Research Institute.

38. Without Insurance it Is Difficult to Obtain Specialized Care Can provide all necessary services using health center's resources Can obtain non-emergency admissions Can obtain specialty referrals Source: M.K. Gusmano, G. Fairbrother, and H. Park, “Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured,” Health Affairs 21, no. 6 (Nov./Dec. 2002): 188–94.

39. Proportion of U.S. Physicians Providing Charity Care Is Declining Percent # #* * Change from 2000-01 is statistically significant at p<.05 # Change from 1996-977 is statistically significant at p<.05 Source: P.J. Cunningham and J.H. May, “A Growing Hole in the Safety Net: Physician Charity Care Declines Again,” Center for Studying Health System Change, Tracking Report No. 13, March 2006.

40. Retaining and Expanding Employer Participation: Maine’s Dirigo Health Annual expenditures on deductible and premium • New insurance product; $1250 deductible; sliding scale deductibles and premiums below 300% poverty • Employers pay fee covering 60% of worker premium • Began Jan 2005; Enrollment 11,000 as of 10/20/05 $2,738 $2,188 $1,638 $1,100 $550 $0 * After discount and employer payment (for illustrative purposes only).

41. Pay for Performance Programs • There are almost 90 pay-for-performance programs across the U.S. • Provider driven (e.g., Pacificare) • Insurance driven (e.g., BC/BS in MA) • Employer driven (e.g., Bridges to Excellence – Verizon, GE, Ford, Humana, P&G, and UPS) • Medicare • 2003 Medicare Rx legislation demonstrations of Medicare physicians a per-beneficiary bonus if specified quality standards are met • Medicaid • RIte Care will pay about 1% bonus on its capitation rate to plans meeting 21 specified performance goals • 4 other states built performance-based incentives into Medicaid contracts – UT, WI, IO, MA • Evaluation of impact still pending Source: Leapfrog report for Commonwealth Fund; additional information available at http://www.leapfroggroup.org/

42. Building Quality Into RIte CareHigher Quality and Improved Cost Trends Cumulative Health Insurance Rate Trend Comparison Percent • Quality targets and $ incentives • Improved access, medical home • One third reduction in hospital and ER • Tripled primary care doctors • Doubled clinic visits • Significant improvements in prenatal care, birth spacing, lead paint, infant mortality, preventive care RI Commercial Trend RIte Care Trend Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003.Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005.

43. Take Away Messages • Closing gaps in insurance coverage is the number one priority action to improve care for vulnerable populations • Support Medicaid funding • Support expansion of insurance coverage • Support adequate funding of primary care capacity in low-income underserved communities • Promote patient-centered primary care • Make it easy to get appointments and obtain care • Shared decision-making can help improve and coordinate care, and engage patients as active partners in their care • Invest in information technology • Invest in chronic care quality improvement • Share best practices • Join learning collaboratives to improve care • Embrace transparency, public reporting, and pay for performance

44. Thank You! • Stephen C. Schoenbaum, M.D., Executive Vice President and Executive Director, Commonwealth Fund Commission on a High Performance Health System • Anne Gauthier, Senior Policy Director, Commonwealth Fund Commission on a High Performance Health System • Alyssa L. Holmgren, Research Associate, Commonwealth Fund Visit the Fund at: www.cmwf.org