Aiming for a Higher Performing Health Care System: Learning from Cross-National Comparisons
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Transcript of Aiming for a Higher Performing Health Care System: Learning from Cross-National Comparisons
THE COMMONWEALTH
FUNDAiming for a Higher Performing Health Care System: Learning from Cross-National Comparisons
Queen’s Health Policy Change ConferenceMay 6, 2015
Toronto, Canada
Robin OsbornVice President and Director
International Program in Health Policy and Practice InnovationsThe Commonwealth Fund
1
What is a High Performing Health System?
• 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
2
Why Do We Do Cross-National Comparisons?
• Benchmark performance
• Track policies and reforms
• Highlight best practices
• Identify variations
• Know what is possible
3
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
0
2
4
6
8
10
12
14
16
18 US (16.9%)
NET (12.1%)*
FR (11.6%)
SWIZ (11.4%)
GER (11.3%)
DEN (11.0%)
CAN (10.9%)
JPN (10.3%)
NZ (10.0%)*
SWE (9.6%)
NOR (9.3%)
UK (9.3%)
AUS (9.1%)*
GDP refers to gross domestic product. Source: OECD Health Data 2014.
Health Care Spending as a Percentage of GDP, 1980–2012
Percent
* 2011
4
Mortality Amenable to Health Care, 2006-07
FR AUS ITA JPN SWE NOR NETH GER NZ DEN UK US0
20
40
60
80
100
120
140
55 57 60 61 61 64 66
76 79 80 83
96
5
* Countries’ age-standardized death rates before age 75; 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 16 High-Income Nations,” Health Policy, published online Sept. 12, 2011.
Deaths per 100,000 population*
6Overall Views of Health Care System, 2013
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
Percent
Commonwealth Fund Annual International Surveys: What We Track
8
– QI/Performance feedback– Chronic illness– Use of the ED– Hospital care– Medications– Physician payment/Incentives– System complexity– Health care coverage– Demographics
• General themes:– Views of the health system– Access and affordability– Primary care/Medical home– Doctor-patient relationship– Prevention/health promotion– Care coordination– Electronic Health Record– Patient safety
• Focus on objective measures rather than opinions.
Cost-Related Access Problems in the Past Year, Among Adults Age 65 or Older
* Had a medical problem but did not visit doctor, skipped medical test or treatment recommended by doctor, and/or did not fill prescription or skipped doses because of the cost.
FR SWE NOR UK NETH SWIZ GER AUS CAN NZ US0
10
20
30
3 4 45 6 6
7 8 9 10
19
Percent*
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
10
Could Get Same- or Next-Day Appointment with Doctor or Nurse When Sick or Needed Care, Among Adults Age 65 or Older
11
FR NZ GER NETH AUS SWIZ UK US NOR SWE CAN0
20
40
60
80
100
83 83 8176
71 6965
57 54 5345
Percent
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Waited Less Than Four Weeks for Specialist Appointment, Among Adults Age 65 or Older
12
US SWIZ NETH AUS NZ GER FR UK SWE CAN NOR0
20
40
60
80
100
8682
7164 62 61 60 60
5046 46
* Base: Saw/Needed to see a specialist in the past two years.
Percent*
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Access to After-Hours Care,Among Adults Age 65 or Older
13
NETH UK FR NZ SWIZ NOR GER US AUS CAN SWE0
20
40
60
80
100
7771 69 69 66 66
6255 54
4137
Source: 2012 and 2014 Commonwealth Fund International Health Policy Surveys.* Base: Needed after-hours care.
Percent who said it was somewhat or very easy to get after-hours care without going to the emergency department*
Emergency Department Use in the Past Two Years, Among Adults Age 65 or Older
14
FR UK GER NOR SWIZ NETH AUS NZ SWE CAN US 0
10
20
30
40
50
15
1921
27 2729 30
3335
39 39
Percent
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Experienced a Coordination Problem in the Past Two Years, Among Adults Age 65 or Older
16
FR NZ NETH AUS UK SWE SWIZ CAN US NOR GER0
10
20
30
40
50
7
20 21 2124 24
2932
3537
41
* Test results/records not available at appointment or duplicate tests ordered; received conflicting information from different doctors; and/or specialist lacked medical history or regular doctor was not informed about specialist care.
Percent*
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Experienced Gaps in Hospital Discharge Planning in the Past Two Years, Among Adults Age 65 or Older
17
US UK AUS CAN FR SWIZ GER NETH SWE NOR0
20
40
60
80
100
28
38 41 44
54 56 56 5967
70
* When discharged from the hospital: you did not receive written information about what to do when you returned home and symptoms to watch for; hospital did not make sure you had arrangements for follow-up care; someone did not discuss with you the purpose of taking each medication; and/or you did not know who to contact if you had a question about your condition or treatment. Base: hospitalized overnight in the past two years.
Percent*
Note: NZ omitted because of small N (fewer than 100 respondents).Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Primary Care Doctors’ Receipt of Information from Specialists18
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
FR NZ SWIZ UK AUS CAN NOR US SWE GER NETH0
20
40
60
80
4744 44
41
3024 22
1613 12
5
Percent who reported after their patient visits a specialist they always receive information about changes to patient’s drugs or care plan
Patient Engagement in Chronic Care Management, Among Adults Age 65 or Older
20
0
20
40
60
80
100
8380
7673
64 62
5347
41 41
30
Percent who have a chronic condition and had a treatment plan for their condition they could carry out in their daily life
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Support for Self-Management Between Doctor Visits, Among Adults Age 65 or Older
21
0
20
40
60
80
100
47
30 2824 24 23
17 16 15 149
Contacts them to check in They can contact to ask questions or get advice
USSW
E NZUK
CANAUS
NOR FRGER
84 83
75 7571
67 6558 55 53
43
Percent who have a chronic condition and had a health care professional that between doctor visits:
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Patients with a Regular Doctor versus a Medical Home, 2011
Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
23
Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home
Percent*
* Reported medical mistake, medication error, and/or lab test error or delay in past two years.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
24
Doctors’ Use of Electronic Medical Recordsin Their Practice, 2009 and 2012
26
Source: 2009 and 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Percent
Doctor Can Electronically Exchange Patient Summaries and Test Results with Doctors Outside their Practice
27
NZ SWE NETH SWIZ NOR FRA UK US AUS GER CAN0
20
40
60
80
100
55 52 49 4945
39 3831
2722
14
Percent
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Doctor Routinely Receives Electronic Prompts About Potential Problems with Rx Dose or Interaction
28
NETH NZ AUS UK SWE US FRA CAN GER SWIZ NOR0
20
40
60
80
100 9389 88 85
70
58
41
3026 25 22
Percent
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Practice Uses Nurse Case Managers or Navigators for Patients with Serious Chronic Conditions
29
Percent
UK NETH NZ SWIZ AUS NOR CAN US SWE GER0
20
40
60
80
100
7873
68 68
59
5144 43 41
20
Note: Question asked differently in France.Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Practice Routinely Receives and Reviews Data on Clinical Outcomes30
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
UK NETH SWE NZ GER US AUS CAN FR SWIZ0
20
40
60
80
100
84 81 78
64
5447
42
23
14 12
Percent
Financial Incentives and Targeted Support31
Percent can receive financial incentives* for:
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Managing patients w/ chronic disease or complex needs
75 70 37 60 77 83 15 49 4 50 21
Enhanced preventive care activities**
42 42 12 23 28 40 17 55 5 37 14
Adding nonphysician clinicians to practice
53 33 3 5 60 36 9 33 4 17 10
Making home visits 57 53 16 51 50 36 45 49 32 20 9
* Including special payments, higher fees, or reimbursements.** Including patient counseling or group visits.Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Policy Implications32
• Insurance design matters
• Having a “medical home” and after-hours care arrangements make a difference
• Innovations in payment and delivery system models are needed to encourage care coordination and better management of complex patients
• Chronically ill patients need to be further empowered and supported in self-management, including between scheduled visits
• Having electronic medical records is not enough – “meaningful use” matters
• More use of performance data and feedback are needed to help primary care practices improve care and patient experiences
• And, as countries innovate and transform their health care systems, there is a tremendous opportunity for cross-national learning
Limitations of Current Cross-National Comparisons
• Imperfect performance measures:o Rely heavily on Commonwealth Fund surveyso Outcome indicators are scarceo Few measures of hospital qualityo Data does not always lead to a value judgment (e.g., are
more MRI machines good or bad?)
• Proliferation of country measures but not typically adopted based on international comparability
• We need more patient-reported outcome measures
• Defining high performance requires subjective judgments
• Numbers don’t tell the full story
33
Overall Health System Performance, 2014
35
Source: The Commonwealth Fund State Scorecard
Ranking based on access & affordability, prevention & treatment, avoidable hospital use and cost, healthy lives, and equity
Long Term Supports:Overall Health System Performance, 2014
36
Source: The Commonwealth Fund Scorecard on Long Term Support Services
Ranking based on access & affordability, choice of setting and provider, quality of life and quality of care, support for family caregivers, and effective transitions
Quality: Mortality Amenable to Health Care, by Race and State, 2009-10
37
Source: Commonwealth Fund State Scorecard on State Health System Performance, 2014
Access: Out-of-Pocket Mean Expenditures, by Race/Ethnicity38
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012
Annual out-of-pocket mean expenditures by race/ethnicity
Quality: Preventable Hospitalizations in New York State, by County
39
Age Adjusted Preventable Hospitalizations Rate per 10,000, Ages 18+ Years, 2008-10
Source: Health Data NY
The Prevention Quality Indicators (PQIs) are a set of measures developed by the federal Agency for Healthcare Research and Quality (AHRQ) for use in assessing the quality of outpatient care for "ambulatory care sensitive conditions" (ACSCs). This indicator is defined as the combination of the 12
PQIs that pertain to adults: (1)Short-term complication of diabetes (2)Long-term complication of diabetes (3)Uncontrolled diabetes (4)Lower-extremity amputation among patients with diabetes (5)Hypertension (6)Congestive heart failure (7)Angina (8)Chronic obstructive pulmonary disease (9)Asthma
(10)Dehydration (11)Bacterial pneumonia (12)Urinary tract infection.
1st & 2nd Quartiles(<144 per 10,000)
3rd Quartile(144-<162 per 10,000)
4th Quartile(162+ per 10,000)
Quality: Readmission Rates, by Hospital
40
Heart Failure 30 Day Readmission Rate, by Hospital, 2010-13
Source: CMS Hospital Compare
Percent
High Performing Hospitals* Low Performing Hospitals**
* Examples from top 10% of hospitals**Examples from bottom 10% of hospitals
Quality: Falls in Long Term Care Institutions, by Nursing Home
41
Percent of Long-Stay Residents Experiencing One or More Falls with Major Injury, 2014
Source: CMS Nursing Home Compare
Percent
High Performing Nursing Homes* Low Performing Nursing Homes**
* Examples in top 10% of nursing homes** Examples from bottom 10% of nursing homes
AcknowledgementsWith appreciation to Dana Sarnak, David Squires, and Michelle Doty for their contributions to this presentation.
And, to our International Survey Partners for their support and expertise:
• Australia: New South Wales Bureau of Health Information• Canada: Canadian Institute for Health Information, Canadian Institutes of
Health Research, Health Quality Ontario, Commissaire à la Santé et au Bien-être du Québec, and Health Quality Council of Alberta
• France: Haute Autorité de Santé and Caisse Nationale d’Assurance Maladie des Travailleurs Salariés
• Germany: Federal Ministry of Health and the German National Institute for Quality Measurement in Health Care
• Netherlands: Ministry of Health, Welfare, and Sport and the Scientific Institute for Quality of Healthcare at Radboud University Nijmegen Medical Centre
• Norway: Norwegian Knowledge Centre for the Health Services• Sweden: Ministry of Health and Social Affairs• Switzerland: Federal Office of Public Health• United Kingdom: The Health Foundation