The Commonwealth Fund. What is a High Performing Health System? Why Do We Do Cross-National Comparisons? Why Do We Do Cross-National Comparisons?

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1 The Commonwealth Fund Aiming for a High Performing Health Care System: Opportunities for Cross-National Learning ISQua International Conference Rio De Janeiro October 6, 214 Robin Osborn Vice President and Director International Program in Health Policy and Practice Innovations The Commonwealth Fund Established by Anna M. Harkness in 191, the mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund s international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. 1 2 What is a High Performing Health System? Why Do We Do Cross-National Comparisons? Goals of a High Performance Health System Best possible health outcomes for everyone Access to care for all Excellent patient experiences patient-centered, coordinated, high quality, safe care for all Lower cost accountable for use of resources and elimination of waste Encourages innovation Learning health care system Americans have the best health care system in the world President Delivers State of the Union Speech 4 Why Do We Do Cross-National Comparisons? Benchmark performance Track policies and reforms Highlight best practices Identify variations Know what is possible Health Care Spending 6 1

2 Health Care Spending as a age of GDP, Health Care Spending per Capita by Source of Funding, 212 Adjusted for Differences in Cost of Living Dollars ($US) 1 US (.9%) 9,, NET (12.1%)* FR (11.6%) SWIZ (11.4%) GER (11.3%) DEN (11.%) CAN (1.9%) JPN (1.3%) NZ (1.%)* SWE (9.6%) NOR (9.3%) UK (9.3%) AUS (9.1%)*, 7, 6,, 4, 3, 2, 1, 1,4 Out-of-pocket spending Private spending Public spending 6, 3,4 1,2 4,11 4,69 4,62 4, , 493 3, ,29 3, , 4,1 4,29 3,691 3,4 3,317 3,6 2,7 2,762 2,6 US SWIZ GER DEN CAN FR SWE AUS* UK NZ* * 211 GDP refers to gross domestic product. Source: OECD Health Data 214. * 211. Source: OECD Health Data 214. Health Care Costs Concentrated in Sick Few Sickest 1 Account for 6 of Expenses Health Services Often Substituted for Social Services Due to Greater Availability Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 29 1% % 1% % Annual mean expenditure per person $9,61 ($27b total spend) 4% 3% 3% Health vs Social Care Spending, % GDP Health care Social care % % 6% $4,62 ($6b total spend) $26,767 ($21 b total spend) % 2% 1% 21% 21% 2% 1% 1% 9% % 1% 11% 1% 11% 97% $7,97 1% % 12% 12% 11% 11% 12% % 9% % 9% 1% 9% % FR SWE SWIZ GER NETH US NOR UK NZ CAN AUS Source: Agency for Healthcare Research and Quality analysis of 29 Medical Expenditure Panel Survey. 9 Source: E.H. Bradley, L.A. Taylor, H.V. Fineberg, The American Health Care Paradox: Why Spending More is Getting Us Less, Public Affairs, Beds in Residential Long Term Care Facilities per 1, Population Age 6+, Achieving Value in Health Care Value Outcomes Cost 2 1 SWE SWIZ NETH NZ FR AUS NOR GER* OECD Median UK DEN* US* JPN *211 Source: OECD Health Data

3 Total Hospital and Physician Costs for Hip Replacement, 212 Dollars ($US) 4, 4, 4, Mortality Amenable to Health Care, 26-7 Deaths per 1, population* , 3,, 2, 1, 1, 9,74 1,927 11,17 11,9 14,39 27, , 2 SWIZ FR NETH UK NZ AUS US Source: International Federation of Health Plans. FR AUS ITA JPN SWE NOR NETH GER NZ DEN UK US * Countries age-standardized death rates before age 7; including ischemic heart disease, diabetes, stroke, and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S. Source: Adapted from E. Nolte and M. McKee, Variations in Amenable Mortality Trends in High-Income Nations, Health Policy, published online Sept. 12, 211. Public Views of Health Care System, 213 Works well, only minor changes Fundamental changes Completely rebuild UK SWIZ NETH AUS NZ NOR SWE GER CAN FR US % 2% 4% 6% % 1% of adults Affordability and Access Source: 213 Commonwealth Fund International Health Policy Survey in Eleven Countries. 1 Cost-Related Access Barriers in the Past Year, 213 * 4 37 Access to Doctor or Nurse When Sick or Needed Care, Same-day or next-day appointment Waited six days or more for appointment UK SWE NOR CAN SWIZ GER AUS FR NZ NETH US Note: Question asked differently in Switzerland. * Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care. Source: 213 Commonwealth Fund International Health Policy Survey in Eleven Countries. 17 Source: 213 Commonwealth Fund International Health Policy Survey in Eleven Countries. 1 3

4 Access to After-Hours Care Used the Emergency Department in Past Two Years, 213 Adults, 213 Easy getting after-hours care without going to the ER Primary care physicians, 212 Practice has arrangement for patients after-hours care to see doctor or nurse AUS GER NETH UK NZ NOR SWIZ FR SWE US CAN Base: Needed care after hours. * In Norway, doctors asked whether their practice had arrangements or there were regional arrangements. Source: 212 and 213 Commonwealth Fund International Health Policy Surveys. 19 Source: 213 Commonwealth Fund International Health Policy Survey in Eleven Countries. 2 * Used the Emergency Department for a Condition that Could Have Been Treated by a Regular Doctor if Available, FR NZ AUS GER NET NOR UK SWIZ SWE US CAN *Used the Emergency Department for a condition that could have been treated by their regular doctor or place of care if available in the past two years. Base: used the Emergency Department and has a regular doctor/place of care. Source: 213 Commonwealth Fund International Health Policy Survey in Eleven Countries Patients Have ed Regular Doctor s Practice in Past Two Years, NETH SWIZ UK AUS SWE NOR US NZ GER CAN FR Source: 213 Commonwealth Fund International Health Policy Survey in Eleven Countries. 24 Patient Engagement in Care Management for Chronic Condition, 211 Chronically Ill Patients reported professional in past year has: Discussed your main goals/ priorities Helped make treatment plan you could carry out in daily life Given clear instructions on symptoms and when to seek care Yes to all three Base: Has chronic condition. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 4

5 1 Pharmacist or Doctor Did NOT Review and Discuss Prescriptions in Past Year, 211 Experienced Coordination Failure in Past Two Years, UK SWIZ CAN US GER NZ AUS NETH SWE FR NOR Base: Taking two or more prescriptions. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. UK SWIZ NZ AUS NETH SWE CAN US NOR FR GER * Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 26 Gaps in Hospital or Surgery Discharge in Past Two Years, 211 did NOT AUS CAN FR Receive instructions about symptoms and when to seek further care Know who to contact for questions about condition or treatment Receive written plan for care after discharge Have arrangements made for follow-up visits Receive clear instructions about what medicines to be taking GE R NETH NZ NOR SWE SWIZ UK US Experienced Medical, Medication, or Lab Test Errors in Past Two Years, UK SWIZ FR GER AUS NETH SWE CAN NZ US NOR Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 27 * Reported medical mistake, medication error, and/or lab test error or delay in past two years. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 2 Doctors Use of Electronic Medical Records in Their Practice, 29 and Primary Care Doctors Infrastructure and Capacity for Improvement NETH NOR NZ UK AUS SWE GER US FR CAN SWIZ 29 Source: 29 and 212 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

6 Primary Care Physician Can Generate Computerized List of Patients by Diagnosis, 212 Primary Care Physician Receives Electronic Prompts About a Potential Problem with Rx Dose or Interaction, UK NZ AUS NETH GER NOR US SWIZ CAN FR NETH NZ AUS UK US FR CAN GER SWIZ NOR * Reported medical mistake, medication error, and/or lab test error or delay in past two years. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 31 * Reported medical mistake, medication error, and/or lab test error or delay in past two years. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Primary Care Doctor Can Electronically Exchange Patient Summaries and Test Results with Doctors Outside their Practice, Practice Uses Nurse Case Managers or Navigators for Patients with Serious Chronic Conditions, NZ SWE NET SWIZ NOR FRA UK US AUS GER CAN UK NETH NZ SWIZ AUS NOR CAN US SWE GER Source: 212 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Source: 212 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. 34 Primary Care Practice Routinely Receives and Reviews Data on Patient Care, 212 routinely receives and reviews data on: Clinical outcomes Patient satisfaction Hospital admissions and ED use % 7% % % % Does Your Practice Have a Process for Identifying Adverse Events and Taking Follow-Up Action? Yes, works well Yes, needs improvement No process UK SWE AUS NZ US FR GER ITA NOR CAN NET 6 Source: 212 Commonwealth Fund International Health Policy Survey of Primary Care Physicians Source: 29 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. 6

7 Financial Incentives and Targeted Support, can receive financial incentives* for: Managing patients w/ chronic disease or complex needs Enhanced preventive care activities** Adding nonphysician clinicians to practice Making home visits AUS CAN FR GER NET NZ NOR SWE SWIZ UK US Efficiency * Including special payments, higher fees, or reimbursements. ** Including patient counseling or group visits. Source: 212 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. 3 Insurance Complexity and Restrictions are a Burden for Patients and Doctors Adults, 213 Spent a lot of time on paperwork or insurance did not cover in past year* 7 Primary care physicians, 212 Insurance coverage restrictions pose major time concern** Medical Homes * Adults spent a lot of time on paperwork or disputes over medical bills and/or insurance denied payment or did not pay as much as expected in the past year. ** Amount of time doctor or staff spend getting patients needed medications/treatments because of coverage restrictions is a major problem. 39 Source: 212 and 213 Commonwealth Fund International Health Policy Surveys. 4 What is a Medical Home? Patients with a Regular Doctor versus a Medical Home, 211 A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. American Academy of Pediatrics Has a regular doctor or place of care Has a medical home UK SWIZ NZ US NOR FR AUS CAN GER NETH SWE Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 42 7

8 Doctor Patient Relationship and Communication, by Medical Home Experienced Coordination Gaps in Past Two Years, by Medical Home reporting positive doctor patient relationship and communication* * 1 Medical home No medical home 1 Medical home No medical home * Regular doctor always/often: spends enough time with you, encourages you to ask questions, and explains things in a way that is easy to understand. Base: Has a regular doctor/place of care. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 43 * Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. * Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home Medical home No medical home Rated Quality of Care in Past Year as Excellent or Very Good, by Medical Home Medical home No medical home * Reported medical mistake, medication error, and/or lab test error or delay in past two years. Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 4 Source: 211 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Convergences of Country Health Care System Objectives and Policy Directions Better access to care for everyone Delivery system integration and transformation Opportunities for Cross-National Learning Payment reform Engaging and empowering patients Maximizing health information technology and using data wisely Ensuring affordability and sustainability 47 4

9 Brazil s Family Health Program The Netherlands Approach to After-Hours Care Provides primary care to % of the population; costs $31- per capita per year; free at the point of care Multidisciplinary teams doctor, nurse, nurse auxiliary, and four to six community health workers work in health units located in geographically defined areas Community health workers each responsible for up to 1 families Primary care: chronic disease management, triage and referral, clinical care, prenatal health education, early child wellness checks Screening for preventive care and health promotion Over, community health workers recruited in past 1 years Large-scale after-hours primary care cooperatives Nurse telephone triage and advice with back-up by physician, walk-in visits and house calls Evidence-based triage protocols and guidelines Adherence rate of 77% to quality guidelines; 2.4% patient-safety incidence rate Home visits: average wait time of 3 minutes; for urgent issues, 7% of patients reached by PCP within the target of 1 minutes Impacts for advanced model integrated with ER: % increase in primary care contact Infant mortality rate was reduced 3% reduction in emergency visits by nearly % during implementation period; a 1% 12% reduction in ambulance calls increase in program coverage 4.% decrease in infant mortality Physicians after-hours workload shrunk from 19 hours to 4 hours per week and job satisfaction increased Source: Macinko J et al., Evaluation of the Impact of the Family Health Program on Infant Mortality in Brazil, Sources: Grol R, Giesen P, van Ulden C, After-Hours Care in the United Kingdom, Denmark and the Netherlands: New 199-, Journal of Epidemiology & Community Health,. 49 Models, Health Affairs, 26; Giesen P et al, Quality of After-Hours Primary Care in the Netherlands: A Narrative Review, Annals of Internal Medicine, 211. Medicall Home (Mexico): 24/7 access to healthcare advice over the phone solving problems immediately % of incoming calls to medical call centre Average over 1 years Instances where health problems were immediately solved through the medical call center Instances where callers were referred to network providers under unrivaled/contractual market price conditions 3 62 x 2 Two thirds of the calls treated on the phone immediately Provides access to over million people Handles over 9, monthly instances Annual savings of $19.7 million due to referring the patient to appropriate level of care Patients have 24/7 access to medical advice and referrals Call center agents rely on protocols developed by the Cleveland Clinic MedicallHome ensures quality by pre-verifying the clinicians in its referral network Low investment / high utilization model with a single call center for the country Currently in the process of expanding to the US and other Latin American and Caribbean countries. Sources: McKinsey & Company; Center for Health Market Innovations 1 Geisinger s ProvenHealth Navigator Patient-Centered Medical Home in the US Target population: patients with multiple chronic diseases Nurses coordinate care, know patients medical histories, help patients access medical and social services, follow and visit patients when hospitalized or discharged, and are available for advice 24/7 Financial incentives for providing quality care Outcomes: Improvement in quality of preventive care (74%), coronary artery disease (%), and diabetes care (3%) for pilot sites 1% reduction in hospital admissions relative to controls, and a 9% reduction in total medical costs at 24 months 7% reduction in costs relative to controls; estimated $3.7 million net savings. Source: Grumbach K, Bodenheimer T, Grundy P, The Outcomes of Implementing Patient-Centered Medical Home Interventions, Patient-Centered Primary Care Collaborative, 29 and 21 Update. 2 Mount Sinai Hospital s Acute Care for Elders (ACE), Ontario Aim: to deliver the right care, in the right place, at the right time for older patients Provides a seamless integrated delivery model that spans the continuum of care Innovative features: high-risk screening in the ER; geriatric emergency management nurses; inpatient unit for high risk medical patients; training of frontline professionals in geriatric care; hospital-wide consultation service in geriatric medicine, psychiatry ad palliative care; intensive care coordination for high risk/high user patients; and, home-based primary and specialty care for frail homebound elders. Inter-professional team-based approach 27.% decrease in mean length of stay 13.4% decline in readmissions 93% reduction in incidence of post-admit nosocomial pressure ulcers Increased patient and staff satisfaction, reduction in staff turnover.7% average reduction of direct cost of care per patient $6.7 million of annual savings in Buurtzorg ( Neighborhood care ) in the Netherlands Small autonomous teams of up to 12 nurses within a neighborhood Nurses are highly qualified (% RNs) and work closely with GPs Each team is responsible for assessment, planning, continuing education, financing, and coordination activities; teams compete for referrals Use portable information technology to keep clients records at hand Target population: chronically ill and disabled, frail elderly, those in need of end of life care, and those recently released from a hospital Impact: Improved efficiency: lower overhead costs and higher productivity of workers Highest client satisfaction rates of 3 home care organizations in 2 Named best care organization employer in 213 for the third year in a row Source: Sinha S, 214. Mount Sinai Hospital s Acute Care for Elders (ACE) Strategy, Presented at the International Experts Working Group on High Need/High Cost Patients, London, Sept , Alders P, Care for Older Adults with Chronic Illnesses and Functional Limitations: Lessons from the Netherlands, Presented at the 214 Harkness Alumni Policy Forum, Washington, DC,

10 Jersey Post s Call & Check Program in the U.K. Postal service workers check in on isolated and frail elderly people on a daily or weekly basis, as part of their usual rounds Drop off medications, give reminders about doctor appointments, ask about immediate concerns, relay any requests or concerns to their doctor or local authority, inform them of social activities 1 minutes for first visit; 3 minutes for subsequent visits. Most clients requested 2 visits per week. All pilot participants (n=) reported positive feedback and said they benefited from the program Postmen said it gave them added job satisfaction Scheme is being expanded and will be jointly funded by the Jersey Post and Department of Health and Social Services. Rollout to the entire island is scheduled for early 21. Bundling Payments for Chronic Conditions in the Netherlands Voluntary bundled payment program introduced for diabetes, COPD, and heart disease in 21 Insurers pay single annual fee to a typically GP-led care group, responsible for providing a nationally-defined package of services for the condition Care groups either provide these services themselves or contract out to other providers No patient cost-sharing for services offered through the bundledpayment Care groups must be transparent and face strict reporting requirements Evaluation of diabetes care found improved coordination, adherence to protocols, and transparency; negative effects included price variations and administrative burden Source: Stanton E, Thinking out of the Mailbox: A Case Study of Jersey Post, Presented at the 214 Harkness Alumni Policy Forum, Washington, DC, Accountable Care Organizations (ACOs) in the U.S. To improve health care quality and curb costs, the Affordable Care Act established Accountable Care Organizations to change the way care is delivered and providers are paid An Accountable Care Organization or ACO is a group of providers doctors, hospitals, home health agencies, and other health care providers who are collectively responsible for the overall costs and quality of care for a defined population of patients. There are two Medicare ACO programs: o Medicare Shared savings Program o Medicare Pioneer ACOs ACOs need to meet certain quality-of-care standards, and, if the ACO saves money, Medicare shares the savings with the organization In some instances, ACO participants may also be financially responsible if costs run over budget. Low-Cost, High Quality Open Heart Surgery at Narayana Hrudayalaya Hospital in India Breakeven Cost for Open Heart Surgery = $1 Volume of Heart Surgeries Mortality Rates A core principle is that providers can innovate in terms of care delivery In 214, a total of 66 accountable care entities 366 Medicare ACOs covering.3 million people - plus 24 non-medicare ACOs Over $3 million in savings generated by Medicare ACOs Source: Centers for Medicare and Medicaid Services, SOURCE: Devi Prasad Shetty, Narayana Hrudayalaya Heart Hospital France Value-Based Care in France and Germany Adjusts patient co-payments based on drug s therapeutic value High-value drugs: Free Medium-value drugs: 3% of drug price Low-value drugs: 6% of drug price Treatments for chronic diseases require no co-payments Germany New pharmaceuticals are assessed for cost-effectiveness and added value over existing treatments Assessments are used to determine coverage and negotiate pricing Sweden s Disease and Medical Device Registries Allow for the collection of longitudinal health outcome data Used to establish best practices and improve the value of the health care system Nearly 9 government-supported registries, including for diabetes, heart surgery, breast cancer, etc. For example, registry to track recipients of hip replacements to gauge differences in devices/surgical techniques Identified high failure rate for oil cup hip implants after 17 negative reports entered in the registry In the U.S., about 17, were done before the defect was identified having a similar U.S. hip replacement registry could have save an estimated $2 billion 9 6 1

11 Personal Health Budgets in Germany and England Germany (199, expanded to include people with mental health needs in 2) Needs assessment and assistance plan created to determine amount of budget; budget holders choose how to receive the services purchased: social care provider and/or personal assistance. Family-based counseling sessions led by nurse twice per year to determine best course of care. Spending reduced by % compared to those with traditional long-term care; patients reported feeling more empowered England ( social care for disabled, 29 - health of people with long-term conditions) Used to employ personal assistants or purchase services that promote in alignment with a personalized health care plan. Amount determined based on needs. UK Department of Health-commissioned evaluation (212) found: Significant improvement in care-related quality of life and psychological wellbeing; benefits stronger where people were given more choice and control and where benefit level was higher (more than 1, per year) Savings for NHS when people had a higher budget; reduction in in-patient costs Long-term care services cost 2-4% less than those purchased by government Sources: Forder J et al., Evaluation of the Personal Health Budget Pilot Programme, Department of Health, November 212; Gadsby EW, Personal Budgets and Health: A Review of the Evidence, PRUComm, February 213; The Health Foundation, Report: Personal Health Budgets, September Home Dialysis in New Zealand In NZ, general consensus that dialysis at home is preferable to dialysis at facilities based on clinical, patient-centered, and economic considerations Home monitoring typically not required, but 24-hour on-call nurse and technician is crucial High prevalence of home hemodialysis and peritoneal dialysis in NZ. Home hemodialysis rate of 1.6% in 211 (9.4% AUS, % US, 2.4% NET, 2.1% UK) Key findings for home hemodialysis: Cost savings due to minimal infrastructure required; about half as expensive as hospital dialysis Up to a 2% lower mortality risk Improves wellbeing of patients who learn to self-manage Sources: Marshall MR, Walker RC et al, Survival on Home Dialysis in New Zealand, PLOS ONE, 214;9(): e9647; Ashton T, Marshall MR, The Organization and Financing of Dialysis and Kidney Transplantation Services in New Zealand, Int J Health Care Finance Econ, 27; Seniors World Chronicle 62 England s Big White Wall A Support Network for Mental Health On-line community of coaches, clinicians and peers to help members self-manage their care, including therapeutic interventions, networking, guided support groups, and live therapy. Has helped more than 14, people Designated as a high impact innovation by the NHS: 2/3 of members would not normally have sought help for mental health issues % of members self-manage their psychological issues through Big White Wall 9% report improvement in mental health 67% adherence rate for GPs issuing Big White Wall prescriptions Saves 37, per 1 members for its mental health services Take Away Messages Cross-national comparisons reflect differences in country health care systems and policies Insurance design matters Cost-sharing or lack of insurance create serious access barriers Subsidies, exemptions, caps on out-of-pocket spending, and other protections for vulnerable populations make a critical difference To better care for High Need/High Cost Patients, we need to: Re-design systems around patients with complex health and social care needs Ensure that information follows the patient Empower patients and families to help manage their care Incentivize providers to provide high quality, efficient, coordinated care As country objectives and strategies converge, innovations in industrialized and developing countries are increasingly relevant and offer a unique opportunity for sparking creative policy thinking at home Source: Big White Wall Acknowledgements 6 With thanks to Chloe Anderson, David Squires, Melinda Abrams, Cathy Schoen, and Michelle Doty for their contributions to the content and production of this presentation. 11