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

Learning from International Surveys

7

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.

9

Access and Affordability

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


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*


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


15

Care Coordination and Transitions

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*


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

19

Chronic Care and Self-Management

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


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:


22

Medical Homes

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

25

Primary Care Practice Infrastructure and Capacity for Improvement

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


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


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


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

Monitoring & Tracking Performance: U.S. Efforts

34

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

aiming for a higher performing health care system: learning from cross-national comparisons

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