1. THE COMMONWEALTH FUND Perfect Care When is performance good enough? –For you; for your family Near-perfection is attainable even in health care The question we all should be asking: –How soon can we achieve perfect care? Within our organization Across the entire health care system

2. THE COMMONWEALTH FUND An Organized Delivery System that Emphasizes Primary and Preventive Care and Is Patient-Centered 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements

3. THE COMMONWEALTH FUND Expand Primary Care and Preventive Services Primary care is the provision of first contact, person-focused ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care. –Barbara Starfield, MD

4. THE COMMONWEALTH FUND Expand Primary Care and Preventive Services Health is better in areas where there are more primary care physicians or more primary care services People who receive care from a primary care physician are healthier Costs of care are lower in areas where there are more primary care physicians or more primary care services More primary care is associated with more equitable care Source: Starfield, B., L. Shi, and J. Macinko. 2005. “Contributions of Primary Care to Health Systems and Health.” Milbank Quarterly 83(3):457-502.

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7. THE COMMONWEALTH FUND Shared Decision-Making: An Important Aspect of Patient-Centered Care

8. THE COMMONWEALTH FUND Why Is Shared Decision Making Important Combines evidence-based practice with patient preferences Many clinical decisions involve value judgments Interventions have different benefits/ risks that patients value differently There is no single right answer for everyone Ethical principle of patient autonomy and legal requirement of informed consent Health care providers cannot automatically infer what patients value, nor can they assume what care decisions are in patients' best interest. Uncertain nature of clinical information

9. THE COMMONWEALTH FUND Center for Shared Decision-Making Dartmouth-Hitchcock Medical Center Provides evidence-based tools to help patients understand trade- offs of medical vs. surgical treatment given their preferences Assists with health care decisions (e.g., videotapes, booklets, websites) Provides follow-up counseling with skilled staff Generally results in lower rates of invasive procedures once the patient understands the trade- offs Kate Clay, BA, MSN, Program Director

10. THE COMMONWEALTH FUND Being There For The Patient The importance of continuity “After-hours” care

11. THE COMMONWEALTH FUND Practice Has Arrangement for After-Hours Care to See Nurse/Doctor Percent 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

12. THE COMMONWEALTH FUND Increase Transparency and Reporting on Quality and Costs 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage

13. THE COMMONWEALTH FUND NCQA/HEDIS Experience Ten years of measuring data has shown that measurement and public reporting leads to improvement: –Children today nearly three times more likely to have had all immunizations as in 1997 –Diabetics today twice as likely to have cholesterol controlled (<130 mg/dL) as in 1998 –More than 96% of cardiac patients prescribed bet- blockers after a heart attack (up from 62% in 1997) Source: NCQA, “The State of Health Care Quality 2006,” 2006.

14. THE COMMONWEALTH FUND Improvements in Use of Beta Blockers After a Heart Attack Source: National Committee for Quality Assurance, The State of Health Care Quality: 2006, Washington, D.C.: NCQA, 2006.

15. THE COMMONWEALTH FUND Expand the Use of Interoperable Information Technology 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage

16. THE COMMONWEALTH FUND Electronic Medical Records and Information Systems Reduce duplicate tests Reduce hospital admissions by having information accessible to emergency room physicians Improve patient care Provide decision support for physicians and patients Facilitate “referrals,” secure transfer of responsibility Reduce medical errors Promote better management of chronic conditions and care coordination –Registries –Performance information –Facilitated by interoperability

17. THE COMMONWEALTH FUND Over 80% Medication Errors Prevented with Computerized Order Entry System Source: Adapted with permission from D.W. Bates et. al. 1999. “The Impact of Computerized Physician Order Entry on Medication Error Prevention.” Journal of the American Medical Informatics Association 6(4):313-21.

18. THE COMMONWEALTH FUND U.S. Adoption of Health Information Technology Range: Medium or High Quality Surveys Best Estimates: High Quality Surveys EHR: ambulatory17% to 25%17% Solo practitioners 12.9% to 13%13% Large groups*19% - 57%39% EHR: hospitals 16% † - 59% †† None CPOE: hospitals4% to 21%5% Source: Presentation by Ashish Jha. “Health IT Adoption: a cross-national comparison.” June 26, 2006.

19. THE COMMONWEALTH FUND Primary Care Practices with Advanced Information Capacity *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. Percent reporting 7 or more out of 14 functions* Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

20. Prescriptions 1039105 = 73% Prescriptions 1289023 = 87% Disch. Letters 682923 = 85 % Disch. Letters 1054314 = 88 % Lab.reports 543040 = 82 % Lab.reports 844528 = 98 % Referrals 115597 = 60 % Referrals Reimbursement 21049 = 92 % GP´swithEDI : 2150 = 98 % SpecialistswithEDI: 639 = 80 % HospitalswithEDI : 63 = 100% Pharmacies withEDI: 331 = 100 % Doctors onCall: 15 = 100 % Health Insurance: 17 = 100 % 79messages/min Lab Requests 44385 = 15 % Network Source: I. Johansen, “What Makes a High Performance Health Care System and How Do We Get There? Denmark,” Presentation to the Commonwealth Fund International Symposium, November 3, 2006. THE COMMONWEALTH FUND MedCom – The Danish Health Data Network

21. THE COMMONWEALTH FUND Reward Performance for Quality and Efficiency 6. Reward Performance for Quality and Efficiency 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage 5. Expand the Use of Interoperable Information Technology

22. THE COMMONWEALTH FUND Medicare/Premier Hospital Quality P4P Demonstration First year results showed significant improvement; composite score increased – –AMI: 87% to 91% –Heart Failure: 65% to 74% –Pneumonia: 69% to 79% –CABG: 85% to 90% –Hip/knee replacement: 85% to 90% Patients receiving better care showed lower mortality (AMI, CHF) Cost savings for hospitals (AMI, Pneumonia, CABG, Hip/Knee) and Medicare

23. THE COMMONWEALTH FUND Percent reporting any financial incentive* Primary Care Doctors’ Reports of Any Financial Incentives Targeted on Quality of Care *Receive of 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

24. THE COMMONWEALTH FUND Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 4. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 2. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage 6. Reward Performance for Quality and Efficiency 5. Expand the Use of Interoperable Information Technology

25. THE COMMONWEALTH FUND There Has To Be Leadership Federal laggership Collaborating public- private groups can lead –IHA (California) –MHQP (Massachusetts) –HQA, AQA –IHI’s new 5 million lives campaign

26. THE COMMONWEALTH FUND IHA (Integrated Healthcare Association) - California Collaboration of multiple stakeholders with a neutral convener –Purchasers – Pacific Business Group on Health –California Association of Physician Groups (225) –California health plans (7) –Consumer Groups –State of California Department of Managed Health Care & Office of the Patient Advocate –California HealthCare Foundation – Rewarding Results grant –NCQA (National Committee on Quality Assurance)

27. THE COMMONWEALTH FUND IHA - California Agreement on measures (technical quality, patient experience, use of health information technology) Competitive stakeholders can collaborate on aligning incentives Agreement to tie P4P to the common measures; but no attempt to agree on payment formulae Results Year over year improvement Scatter in performance –This isn’t sufficient to achieve perfection

28. THE COMMONWEALTH FUND Massachusetts Health Quality Partners (MHQP) MHQP –A broad-based coalition of physicians, hospitals, health plans, purchasers, and government agencies –Seeks to improve health care through collaboration among all stakeholders –Common quality agenda, including shared guidelines and tools, as well as becoming a source for comparative health quality information Public Reporting –In 2006, started Medical Group level reporting of 15 quality measures and patient satisfaction measures –Moving forward, will incorporate Medicare/Medicaid data (designated as one of the 6 Ambulatory Quality Alliance pilots) –Beginning to explore new efficiency measures and their role in public reporting

29. THE COMMONWEALTH FUND Achieving a High Performance Health System: What You Can Do

30. THE COMMONWEALTH FUND What You Must Do –Take An Active Role In Improving Your Own Care –Take An Active Role In Improving Care In Your Health System –See The Positive Side To Change What We All Must Stop Doing –Protect Our Turf (there is still a lot of turf to go around)

31. THE COMMONWEALTH FUND Achieving a High Performance Health System: What You Can Do Advocate for affordable health insurance for all Establish and publicize policy on discounted care for uninsured and low-income Invest in chronic care improvement, transitional care Share and help spread best practices; join collaboratives to implement proven quality and patient safety measures Improve patient-centered care; survey and respond to patient concerns Support transparency; public reporting of clinical quality, patient- centered care, and efficiency Accelerate adoption of IT; ensure patient access to an integrated personal health record Participate in demonstrations that reward high quality and efficient care; be actively involved in design of incentivized payment systems Consider options for better coordination and integration of care delivery; shared accountability for patient care through physician- hospital organizations; accountable medical homes

32. THE COMMONWEALTH FUND Thank You! Karen Davis, President, The Commonwealth Fund Anne Gauthier, Senior Policy Director, Commission on a High Performance Health System, The Commonwealth Fund Tony Shih, MD, Senior Program Officer, Quality Improvement and Efficiency, The Commonwealth Fund Elizabeth Sturla, Executive Assistant, The Commonwealth Fund

33. THE COMMONWEALTH FUND Visit the Fund www.cmwf.org