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 kd@cmwf.org www.commonwealthfund.org

Goals for a High Performance Health System HIGH QUALITY CARE ACCESS AND EQUITY FOR ALL LONG, HEALTHY, AND PRODUCTIVE LIVES EFFICIENT CARE SYSTEM AND WORKFORCE INNOVATION AND IMPROVEMENT

US Scorecard: Why Not the Best US Scorecard: Why Not the Best? Commonwealth Fund Commission National Scorecard Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 3

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 STATES OVERALL RANKING (2007) 3.5 5 2 1 6 Quality Care 4 2.5 Right Care 3 Safe Care Coordinated Care Patient-Centered Care Access Efficiency Equity Long, Healthy, and Productive Lives 4.5 Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102 * 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

Mortality Amenable to Health Care LONG, HEALTHY & PRODUCTIVE LIVES Mortality Amenable to Health Care Deaths per 100,000 population* * 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 5

International Comparison of Spending on Health, 1980–2005 Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP 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 6

Overall Views of the Health Care System in Seven Countries, 2007 and 1998 Percent reporting: AUS CAN GER NETH NZ UK US Only Minor Changes Needed 2007 24 26 20 42 16 1998 19 * 9 25 17 Fundamental Changes Needed 55 60 51 49 56 57 48 58 46 Rebuild Completely 18 12 27 15 34 30 23 32 14 33 * Germany and the Netherlands did not participate in the 1998 survey. Sources: 1998 and 2007 Commonwealth Fund International Health Policy Surveys

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

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 4 12 1 19 25 Skipped test, treatment or follow-up 17 3 Percent who said yes to at least one of the above 26 21 37 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 Percent AUS GER NETH NZ UK CAN US AUS GER NETH NZ UK CAN US Source: 2007 Commonwealth Fund International Health Policy Survey

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 Source: 2007 Commonwealth Fund International Health Policy Survey

Primary Care Doctors in Canada and U. S Primary Care Doctors in Canada and U.S. Less Likely to Have Arrangement for Patients’ After-Hours Care to See Nurse/Doctor Percent 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.

More Canadians and Americans Visited the Emergency Room For Condition Doctor Could Have Treated Than Other Countries Percent Source: 2007 Commonwealth Fund International Health Policy Survey

Only Half of Adults in Canada and U.S. Have a Medical Home Percent 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

Canadians with Chronic Condition Less Likely to Receive a Reminder for Preventive Care, Even With a Medical Home Base: Adults with a chronic condition Percent with reminder 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

Less Than One in Three Canadians Without a Medical Home and a Chronic Condition Receive a Care Plan to Manage Condition at Home Base: Adults with a chronic condition Percent with care plan 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

Engaging Patients and Managing Care Chronic Care Model and Medical Home Fit Together Chronic care model requires a team, patient-centered approach, IT support Country initiatives around disease management or frail elderly have elements related to building medical homes

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 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)

Canadian and American Patients with a Medical Home More Likely to Receive Quality Care from Doctor Percent rated care received “excellent” or “very good” 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

Physicians in Canada and U. S Physicians in Canada and U.S. Less Likely to Participate in Activities to Improve Quality of Care AUS CAN GER NETH NZ UK US Percent in past two years who: Participated in collaborative QI efforts 58 48 76 70 78 49 Conducted clinical audit of patient care 45 69 46 82 96 Percent reporting their practice: Sets formal targets for clinical performance 26 27 35 41 50 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: AUS CAN GER NETH NZ UK US Test results or records not available at time of appointment 11 8 7 9 10 15 Duplicate tests: doctor ordered test that had already been done 5 4 6 14 Percent with either coordination problem 18 19 12 13 23 Source: 2007 Commonwealth Fund International Health Policy Survey

Physicians in Canada and U. S Physicians in Canada and U.S. Less Likely to Receive Incentives for Quality Percent of physicians reporting any financial incentive for quality of care* * 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.

Where are the U.S. and Canada on IT? Percent reporting 7 or more out of 14 functions* Percent reporting EMR *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.

Doctors Reporting Routinely Receiving Alerts about Potential Problem with Drug Dose/Interaction Percent of physicians Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

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

Take Away Messages 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 To improve physician satisfaction with practice

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

Thank You! Robin Osborn, Vice President and Director, International Program in Health Policy and Practice ro@cmwf.org Stephen C. Schoenbaum, M.D., Executive Vice President and Executive Director, Commission on a High Performance Health System, scs@cmwf.org Cathy Schoen, Senior Vice President for Research and Evaluation cs@cmwf.org Katherine Shea, Research Associate ks@cmwf.org Sign up for Commonwealth Fund e-alerts – http://www.commonwealthfund.org