National Juxtapositions in Healthcare Delivery & Quality:

An Overview & Analysis of the Commonwealth Fund Annual Report

Eric LuellenAmerican Healthcare System

May 2016

Who & What is the Commonwealth Fund?• “A private foundation that aims to promote

a high performing health care system.” Advocates for US healthcare system reform.

• Founded in 1918 by spouse of the Harkness Family, a Rockefeller family and Standard Oil Company financier.

• Endowment of $99 million from 1919 to 1959 ($852M today).

• Since 2013, lead by Democratic political activist David Blumenthal (former chief healthcare policy advisor to Dukakis and Obama); and, COO/CFO/Treasurer/Secretary is a Hillary Clinton political appointee.

(Commonwealth Fund, 2016)

Annual Reports

• Compares the US health care system across 80 metrics in five categories with 10 of the world’s 195 sovereign nations.

• Began in 2000; however, most known for reports from 2011-2015• This analysis is based on their 2014 report: “Mirror, Mirror on the

Wall: How the Performance of the U.S. Health Care System Compares Internationally.”

• Primary “Finding:” The US has the worse health care system in the world because it lacks universal government health care.

(Commonwealth Fund, 2016)

Ratings & Conclusions

(Commonwealth Fund, 2016)

Ratings & Conclusions

The United States spends the most per citizen on health care

The United States spends the most on health care as a percentage of gross domestic product

(Commonwealth Fund, 2016)

Ratings & Conclusions

The United States healthcare delivery and quality has allegedly fallen from 5th in the world to 11th in the world amongst 11 industrialized nations

The decline is accelerating (increasing at an increasing rate) by falling four places in one year (2013-2014).

(Commonwealth Fund, 2016)

The “Worst” Categories & OverallDefinitions1. Timeliness of Care – A seven-question composite related to whether patients could see a

provider same-day without an appointment, on holidays, emergency waits over two hours, whether doctors perceive patients have to wait for tests and treatment, specialist waits over two months, and elective procedure waits over four months. (Karen Davis, 2014)

2. Efficiency – Healthcare efficiency, for the purposes of this report, is defined by analogy thusly: “an efficient, high-value health care system seeks to maximize the quality of care and outcomes given the resources committed, while ensuring that additional investments yield net value over time.” (Karen Davis, 2014)

3. Equity – The World Health Organization defines healthcare equity as “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.” The WHO is careful to specify that this includes the degree to which these inequalities are being corrected. (WHO, 2016)

4. Healthy Living – A three-question composite related to “mortality amenable to medical care,” infant mortality, and predicted life-expectancy at age 60 years. (Karen Davis, 2014)

(Commonwealth Fund, 2016)

Improving Timeliness of Care with Health IT

(Kahn, 2015)

Challenges• Quality control & effectiveness fears• Regulating quality inter-jurisdictionally

because of Internet and globalization• Palpitations and contact unavailable.

Telehealth Consultations• Expands access while overcoming

geographic, economic, and sociological barriers

• Potential to improve health care by increasing access to more knowledgeable specialists

• Has potential to lower health care costs by reducing travel and overhead.

• Improves timeliness by finding providers when available, no wait.

Improving Efficiency with Health IT

(William B. Weeks, 2016)

Patient Engagement Platforms• Complex event processing (CEP) can proactively

monitor & alert behaviors• Prevents medication non-adherence and drug-

drug interactions• Coordinates care across disparate team of health

care providers• Improves patients’ perceptions of care• Provides big data for knowledge discovery and

evolving health care• Promotes shared decision making• Prevents adverse events to reduce cost and

improve value and efficiency – pay for patient performance

Challenges• Quality control & effectiveness fears• Regulating quality inter-jurisdictionally

because of Internet and globalization• Palpitations and contact unavailable.

Improving Equity with Health IT

(Halamka, 2015)

Clinical Decision Support Systems• Patients anywhere can have

superlative diagnoses quality, even better than human.

• Reduces gaps or delays between diagnoses and treatment.

• May be the future of much of medical diagnoses because of sequencing and functioning of genome, biome, and proteinomics.

Challenges• Asking the right questions key; limited

patient knowledge is challenging.• Natural language (NLP) is also

problematic, few standardized terms.• Adoption by providers challenging

because it evolves their role & power.

Commonwealth Fund Reports: Fact or FictionMethodological and statistical analysis reveals that the report is more appropriately classified as political propaganda than science;It relies on statistics that are knowingly inaccurate to advocate a political outcome, which is also an inaccurate conclusion;

In other words, it draws non-factual conclusions from knowingly inaccurate data that, even if the data were accurate, would reasonably lead to different conclusions.

For example:• Each country uses different accounting

methods, which the authors fail to reconcile;• Globally, health care costs are

commonly under reported because provider incomes are excluded;

• European reimbursement rates in at least nine countries are known to be off by as much as 50%;

• One key metric, survival rates, is excluded from their analysis;

• The conclusion cannot be that countries with universal health care rank higher because each of those countries has a different system of care. (John Goodman, 2009)

Lessons Learned – The Pros & The ConsThe Cons• The Commonwealth Fund is more of a

political advocacy group than an objective and independent scientific authority.

• Its reports distort facts, report facts it knows or should know are false, and claim unrelated conclusions to support their political agenda.

• Different accounting systems make it difficult to compare national health systems; however, the WHO has ranked the US health care system at 37 out of 195, not the lowest.

The Pros• The US, and many nations, have

significant room for improvement in the timeliness, efficiency, and equity of health care delivery.

• Health information technology (HIT) such as telehealth, patient engagement systems, and clinical diagnostic decision support systems have a probability of significantly improving these areas.

Works CitedCommonwealth Fund. (2016, May 21). About Us: Foundation History. Retrieved from The Commonwealth Fund: http://www.commonwealthfund.org/about-us/foundation-history

Halamka, J. D. (2015, December 23). Using Big Data to Make Wiser Medical Decisions. New England Journal of Medicine, pp. http://catalyst.nejm.org/using-big-data-to-make-wiser-medical-decisions/

John Goodman, L. G. (2009, March 10). Health Care Reform: Do Other Countries Have the Answers? . Retrieved from National Center for Policy Analysis: http://www.ncpa.org/pdfs/sp_Do_Other_Countries_Have_the_Answers.pdf

Kahn, J. M. (2015). Virtual Visits — Confronting the Challenges of Telemedicine. New England Journal of Medicine, 1684-1685.

Karen Davis, K. S. (2014, June). Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. Retrieved from The Commonwealth Fund: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf

WHO. (2016, May 21). Health Systems: Equity. Retrieved from World Health Organization: http://www.who.int/healthsystems/topics/equity/en/

WHO. (2016, May 21). World Health Organization’s Ranking of the World’s Health Systems. Retrieved from The Patient Factor: http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems /

William B. Weeks, J. N. (2016, March 9). Patient-Reported Data Can Help People Make Better Health Care Choices. New England Journal of Medicine Catalyst, pp. http://catalyst.nejm.org/patient-reported-data-can-help-people-make-better-health-care-choices/

DisclosuresThe author is the co-founder of iDok, and currently serves as the Chief Executive Officer of Bioinformatix, LLC, the developer of Rx&You.