A National Framework for Change 2008. 2 The Challenge In a country that expects the best of...

A National Framework for Change2008

2

The Challenge

In a country that expects the best of everything we fail to achieve the best in health.

What must be done to meet the health and

health care challenges of our future?

• Chronic illness on the rise• Consumer dissatisfaction• High health care and insurance costs

4

Chronic illness is on the rise• Half of Americans have one or more chronic illnesses

• 80% of spending is linked to chronic illness

• Much of this is avoidable

• Obesity has doubled; Diabetes is on the rise

Source: Centers for Disease Control and Prevention.

A Sicker America

Prevalence of Obesity1, U.S. Population, 1990-2002

Obesity

0%

5%

10%

15%

20%

25%

90 91 92 93 94 95 96 97 98 99 00 01 02

Perc

enta

ge o

f Pop

ulatio

n

5

Chronic illness is on the rise• Half of Americans have one or more chronic illnesses

• 80% of spending is linked to chronic illness

• Much of this is avoidable

• Obesity has doubled; Diabetes is on the rise

Source: Centers for Disease Control and Prevention.

A Sicker America

Prevalence of Diabetes1, U.S. Population, 1990-2005

Diabetes

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05

Per

cent

age

of P

opul

atio

n

6

• BiologyHigh risk factors; family history; physical and mental health problems

• Physical environmentExposure to toxins; hazards at work or at home; air pollution

• Social environmentPoverty; lack of education; homelessness; lack of transportation; violence

• BehaviorSmoking; poor eating habits; lack of exercise; drug and alcohol abuse

* Adapted from Healthy People 2010, a report by The U.S. Department of Health and Human Services

A Sicker America

Factors Harming Health Are On the Rise

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America’s Health Must Improve

Without change, America’s health care capabilities and finances will be overwhelmed

As a society we must:• Provide access to education and preventive care• Help all reach their highest potential for health• Reverse the trend of avoidable illness

As individuals we must:• Achieve healthier lifestyles• Take responsibility for our health behaviors and choices

Each one of us must take action

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The Benefits

• Healthy infants = healthy kids

• Healthy kids = success in school

• Healthy kids = healthy adults

• Healthy adults = healthy seniors

• Healthy individuals = healthy families, healthy workers, healthy communities and a healthy economy

A healthy America

is a productive and vibrant America

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Good 26%

Fair 30%

Poor 29%

Very Good10%

Excellent4%

Don't know 1%

6 in 10 Americans rate the health care system as fair or poor

America’s Health Care Must Improve

People are dissatisfied

with the health care system

Source: Employee Benefit Research Institute, 2007.

59% fair or poor

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2007

Not at all satisfied

30%

Not too satisfied

18%

Somewhat satisfied

28%

Very satisfied

13%

Extremely satisfied

5%

No experience

3%

Don't know2%


Health care costs are high• Highest spending per person among industrial countries• High costs weaken America in today’s global economy• Americans are increasingly angry about high costs

Source: Employee Benefit Research Institute, 2007.

2005

Not at all satisfied

19%

Not too satisfied

14%

Somewhat satisfied

32%

Very satisfied

21%

Extremely satisfied

7%

No experience

6%

Don't know

1%

Dissatisfaction with health care costs grew 15 percentage points in two years

33% 48%

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Health care in America can be

better and more affordable

America deserves care that is:• Safe and free from harm• Provided at the right time, when care is needed• The recommended care every time• Efficient and affordable• Without bias• Personalized and sensitive to each individual’s needs

Adapted from the Institute of Medicine Crossing the Quality Chasm, 2001.

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Can We Envision a Different Future?

• Health and health care are basic human needs and no one goes without

• Everyone has prompt access to needed health care

• Everyone is treated with dignity and respect

• Everyone has the opportunity to reach their highest potential for health

• Health and health care is without bias

• Improving the health of our nation is viewed as a common good and good for our nation

A new vision for America

Health for Life

Better Health. Better Health Care.

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What Does This Vision Mean?

For America’s Health:• America is #1 in health status among nations

• Trend in avoidable chronic disease is reversed

• People lead healthy, balanced lives

For America’s Health Care:• Health care is efficient, affordable and of high quality

• Everyone has coverage and access to care

• Care experience exceeds expectations

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Action By All

Improving America’s health is a great common cause that calls for leadership,

participation and shared responsibility

• Every individual• Every employer• Every insurer• Every health care supplier• Every community• Every state, local and the national government• Every doctor, hospital and all care providers

Now is the time to do better

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• Reform will require changes in public policy at the federal and state level

• The following public policy ideas for change were developed by six expert advisory groups involving nearly 100 different organizations (consumers, business, labor, insurers, physicians, nurses, hospitals, and others)

• These ideas represent a strong consensus across the groups of policy ideas that begin to move America in the right direction

• These ideas are intended to guide policy makers with concrete suggestions toward a common path for creating change in health and health care in America

Opportunities for Leadership: By Stakeholders in Coalition

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Focus on Wellness

Good health – physical, mental, and oral – is essential for a productive and vibrant America. A focus on wellness must be integrated into the lifecycle, from birth to death, and be encouraged in our homes, schools, workplaces and communities.

Goals

• Healthier lifestyles, better compliance with recommended care and lower rates of preventable diseases• Guarantee access to primary care• Focus on prenatal care and children’s health at an early age

Public Policy Ideas for Change

• Invest in the provision of primary care services• Promote healthy pregnancies and newborns• Invest in America’s public health• Provide incentives to encourage healthy choices and behaviors• Provide a national investment in school and community-based health• Call for a national media campaign focusing on healthy lifestyles• Provide support and coaching needed to change unhealthy behaviors• Enhance health professions education to include a focus on wellness• Focus on chronic care management• Create an objective, trusted source of consumer health information and education

Go to www.aha.org for more detail.

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Efficient Affordable Care

Efficient Affordable CareAmerica will not be satisfied unless and until the cost of health coverage and health care are affordable.

Goals

• More informed decision making• Better manage chronic disease• Evaluate the efficacy and use of new technologies and medicines • Spend resources on care, not paperwork and legal costs• Well-educated workforce in sufficient numbers and with needed mix of skills


• Simplify the working of public and private insurance• Focus on chronic care management• Create a better alternative to today’s liability system*• Test payment redesign to reward quality providers

who follow recommended “best practices”* • Redefine roles for workers to meet future care needs• Renovate the education of health care professionals

and the broader health care workforce• Make available to consumers meaningful information

on the quality, price, use, and comparative effectiveness of health care services

• Analyze the comparative effectiveness, risks, and benefits of new technologies, medicines, practices, and procedures for individual conditions

• Expand educational capacity and emphasize early math and science learning to meet current and future health care workforce needs

• Invest in America’s public health • Test payment redesign to give provider groups a single

amount to manage the entire episode of a patient’s care and better coordinate care*

• Adequately fund national performance improvement measurement*

* See specific AHA proposal.Go to www.aha.org for more detail.

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Highest Quality CareMotivate doctors, nurses, hospitals, nursing homes, and others to work together and team up with patients and families to make sure the right care is given at the right time and in the right setting.

Goals

• Increase development and use of evidence-based care• Reward care outcomes• Support doctors, hospitals and others in working together to coordinate care on behalf of patients• Coordinate treatment of physical and behavioral health needs• Increase availability and use of compassionate end-of-life care


• Modernize laws and regulations to allow doctors, hospitals, and others to work together in teams or “networks”*

• Create a national investment to research the best evidence in patient care and effective quality improvement strategies. Develop methods for speeding the adoption of these methods within the field

• Clinical integration*• Renovate the education of health care professionals

and the broader health care workforce • Test payment redesign to reward quality providers who

follow recommended “best practices”*• Test payment redesign to give provider groups a single

amount to manage the entire episode of a patient’s care and better coordinate care*

• Integrate physical and mental health care delivery

• Expand options for end-of-life care at home• Require everyone to complete and providers to honor a

summary of wishes regarding life-sustaining treatment• Adequately fund national performance improvement

measurement*• Redesign coverage and payment to guarantee parity• Make available to consumers meaningful information

on the quality, price, use and comparative effectiveness of health care services

• Create a better alternative to today’s liability system* • Analyze the comparative effectiveness, risks, and

benefits of new technologies, medicines, practices and procedures for individual conditions

• Reduce health disparities and inequity in health care delivery


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Best Information

Good information is the gateway to good care.

Goals

•Increase patient safety•Reduce duplicative testing, unnecessary costs and patient hassle•Ensure open communication between patients and providers•Speed the adoption of health information technology•Ensure easy access for patients to their medical records and health information•Enable better care coordination


• Speed the creation of electronic health records and personal health records by selecting and using “interoperable” health standards*

• Drive the secure exchange of clinical information among and across different providers of care*• Encourage private sector creation and use of unique, confidential health information identifiers to accurately and

securely link patients to their health records • Fundamentally reform the payment model to encourage specific IT adoption by health care professionals and

hospitals* • Provide incentives for health care suppliers and insurers to enable the use of IT • Conduct research and development of the market requirements and business models needed to create the next

generation systems and technologies • Allow providers and community collaboratives to share information exchange capabilities • Establish national models for data use that will facilitate community health improvement • Renovate the education of health care professionals


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Health Coverage for All… Paid for By All

Health coverage for all is a shared responsibility. Everyone – individuals, business, insurers and governments – must play a role in both expanding coverage and paying for it.

Goals

• Health coverage for all• Increase access to care for all• Increase insurance efficiency• Protect against high cost health events• Reduce differences in care by race, ethnicity and other characteristics


• Every individual must have and contribute to the cost of health care coverage• Every employer must take responsibility for providing health care coverage for their employees and contribute to

the cost• Every insurer must guarantee access to coverage that is affordable, gives consumers the protection they need, and

delivers value• Governments must maintain their current responsibility for coverage for seniors, disabled and certain low income

people• Collective financing will be needed

Go to www.aha.org for more detail.

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Opportunities for Leadership: By Each Stakeholder

• While some improvements will require changes in public policy, many changes are already being made and must continue

• The nation’s hospitals and health systems commit to pursue performance improvement in the care we provide and in improving the health of our communities

• To improve America’s health, everyone must lead, participate and share responsibility. We call on others – physicians, insurers, employers, vendors, and government – to do their part as well

• Following are examples of actions that stakeholders can take today to improve health care in America

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Opportunities for Leadership: Hospitals

Safe• Make effective use of information and clinical technology

designed to improve safety.• Implement specific practices shown effective in improving

safety.• Redesign care processes to eliminate defects.• Collect and report errors in care to patient safety

organizations.• Support patients, their families, doctors and other caregivers

when patient harm occurs. Timely• Reduce emergency department wait times.• Reduce the time between scheduling an appointment and

seeing a health care practitioner.• Speed procedures, test results, patient diagnosis and

treatment.• Smooth the movement of patients throughout their care

delivery experience. Effective• Ensure the use of current best evidence in patient care.• Share information with clinicians on how their clinical practice

compares to "best practices" or "benchmarks”. • Ban unhealthy products on hospital campuses, such as

tobacco, use of trans fats, or availability of unhealthy foods.• Promote better nutrition and fitness among our own hospital

employees and within the broader community.• Lead community based initiatives to reduce obesity, diabetes,

HIV or other local needs. Efficient• Employ techniques to optimize performance.• Reduce process variation to improve reliability of care.• Manage organizational variability to streamline processes.• Adopt health information technology to eliminate duplication of

effort and reduce administrative costs.

Efficient (cont.)• Participate in payment approaches that reward efficiency and

quality.• Track patients with chronic conditions and provide them with

effective chronic care management to avoid hospitalization.Equitable• Collect patient data on race, ethnicity and language to look

more closely at hospital quality and patient satisfaction. • Make translation services available for patients and their

families.• Strengthen the diversity of hospital governance, management

teams and workforce.• Provide employees training in cultural competence.• Work with community leaders and organizations that serve

racial or ethnic minorities or other groups to reduce care disparities.

Patient-centered• Encourage active patient and family involvement in care

delivery and decision-making.• Customize care to meet each individual patient’s needs and

preferences.• Educate patients and families on palliative care and end-of-life

care options.• Embrace transparency in the reporting of quality and pricing

information to help people be better educated patients.• Ensure the protection of patient privacy and the confidentiality

of medical information.• Expand the health care literacy of communities and patients

served.• Integrate the care delivered by physicians, nurses and others

to create a coordinated, seamless continuum of care for patients.

Examples of ways to reach the goal:

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Opportunities for Leadership: Physicians

Safe• Consistently use current best evidence in

patient care.• Publicly report both quality and pricing

measures.• Make effective use of information technology

designed to improve safety. • Support patients, their families, and other

caregivers when patient harm occurs.

Timely• Participate in providing on-call emergency

department coverage. • Extend physician group office hours to

include evenings and weekends.• Reduce time between scheduling an

appointment and seeing a health care practitioner.

Effective• Consistently use current best evidence in

patient care.

Efficient• Eliminate duplication of tests and procedures.

Equitable• Achieve cultural proficiency. • Commit to serving Medicare and Medicaid

patients. • Commit to serving a fair share of your

community’s un- and underinsured individuals.

Patient-centered• Make effective use of information technology

for patient registration and medical records. • Use systems to remind patients of needed

follow up care and visits.• Document all follow up care directions in

writing.• Reduce patient waiting times.


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Opportunities for Leadership: Business/Employers

Efficient• Agree on standardized, meaningful, accurate

and reliable measures for cost and quality reporting.

• Support standardization of administrative activities and costs across insurers.

• Support standardized insurance benefit packages across insurers.

Equitable• Offer coverage to full-time employees.• Offer coverage to part-time employees.• Offer “employee and spouse” coverage in

addition to “employee and family” coverage.

Patient-centered• Offer healthy workplace menus.• Offer healthy vending machine selections.• Ban smoking in or outside the workplace.• Remove cigarette machines from the

workplace.

Safe• Develop healthier food product alternatives.• Endorse and advertise marketing standards

that promote healthy behaviors.

Timely• Eliminate policies that reward workers for not

using sick leave to seek medical care.

Effective • Use incentives to reward healthy employee

behaviors. • Offer workplace health units for primary care

needs.• Provide workplace wellness programs.• Require insurers to have chronic disease

management programs.


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Opportunities for Leadership: Insurers

Efficient (cont.)• Adopt a single uniform bill across insurers.

Equitable• Guarantee coverage policies will be issued

equally to everyone.

• Pool risk across all policy holders.

• Work with other insurers to create coverage portability across plans and employers.

• Eliminate benefit “carve outs.”

• Eliminate lifetime caps on coverage.

• Create parity in coverage for physical and mental health needs.

Patient-centered• Give enrollees smart cards that electronically

access co-payment and deductible requirements.

• Give enrollees electronic access to claims information so they can share it with other providers.

• Adopt automated prescription delivery for maintenance medications.

Safe

Timely• Ensure provider networks include 24-7 access to

urgent care in a setting other than the emergency department.

Effective• Include coverage for prevention and wellness in

all policies.

• Collect and share outcomes data across insurers.

• Base coverage decisions on comparative effectiveness research.

• Share practice variation data with physicians and hospitals.

Efficient• Make information about insurance products,

offerings and prices transparent and easily available to the public.

• Develop a single source for coverage determination and claims processing across insurers.


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Opportunities for Leadership: Vendors

Efficient• Voluntarily join to select and implement

information technology standards to create greater interoperability.

• Voluntarily set standards that create compatibility among different manufacturers’ clinical technologies.

Equitable• Provide discounted drugs and devices to

uninsured patients of limited means.• Ensure that pharmaceutical and device

research and testing is done with appropriate representation of our increasingly diverse population and be relevant to all populations.

Patient-centered

Safe• Standardize device-specific numbering.• Standardize pharmaceutical identification at

the unit dose level.• Lead in pharmaceutical labeling that

eliminates confusion and error.

Timely

Effective• Do not promote off label uses of medications.• Do not facilitate unapproved device

modification.• Voluntarily participate in the creation of

comparative effectiveness information on the risks, benefits and costs of new technologies, therapies and treatments.


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Opportunity for Cost Savings

• Improve health status• Reduce the burden of chronic disease• Reduce medical errors • Reduce waste• Improve efficiency • Reduce administrative costs• And more…

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Examples of What the Research Says

Goal Health ImpactAnnual Savings

Opportunity

To Whom Savings Accrue

Reduce incidence of 18 types of medical injuriesJAMA 290, no. 14 (2003)

2.4 million avoidable hospital days $9 billionProviders and payers

Reduce variation in care for 5 chronic conditionsNat’l Committee for Quality Assurance, 2005

21,500-52,100 deaths avoided $1 to 3 billionPayers/

employers

Interoperable EMR, central data repository, clinical decision supportHealth Affairs 24, no. 5 (2005)

Increased efficiency, elimination of 2.2 million adverse drug events, and reduced admissions, ED visits, and lost days of work

$121 billion System-wide (mostly payers and consumers)

Benchmark performance: prenatal careNat’l Committee for Quality Assurance, 2005

1000 – 1750

deaths avoided$2 million

Payers/

employers

Weight managementHealth Affairs Web Exclusive (2004)

300,000 deaths attributable to obesity related conditions

$177 billion Payers/

employers

Expand coverage

Health Affairs Web Exclusive (2004)

18,000 deaths avoided

$65 – 130 billion

(in increased economic

output)

Society

Expand coverage

Families USA, 2005

Reduced premium levels due to reduced cost shift

$29 billion

(For doctors and hospitals)

Privately insured (employers and individuals)

Note: Savings is not necessarily additive across studies. Savings not reflective of investment required to achieve performance level indicated.

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Measuring Progress

Measure Vision

Ranking of U.S. health status compared to other nations* 1st

Focus on Wellness: Percent of people receiving recommended prenatal, preventive and primary care

100%

Most Efficient Affordable Care:

Percent growth in per person health spending above inflation

0%

Highest Quality Care:

Percent of people receiving evidence-based medicine or “best practices”

100%

Best Information:

Percent of people who have an electronic health record 100%

Health Coverage for All… Paid for By All:

Percent of people with health coverage100%

* Based on World Health Organization

Includes such measures as infant mortality, average life expectancy, etc.

How will we know that we are on the right path?

A National Framework for Change2008

A National Framework for Change 2008. 2 The Challenge In a country that expects the best of...

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