Re-Engineering Care for 21st Century High Performance Health SystemsPotential to Improve and Opportunities to Learn

Insights from Cross-National Experiences

Sydney, June 19, 2014Cathy Schoen, Senior Vice President

The Commonwealth Fundwww.commonwealthfund.org

2Improving Primary Care and Care Systems for 21st Century Health Systems

• Patient-Centered, High Performance Care Systems– Goals: Accessible, High Quality (Outcomes/Health)

and Sustainable Costs– Potential of primary care, teamwork and care

continuum • Insights International Surveys

– Insurance design matters for access, affordability and complexity

– “Medical homes” make a positive difference • Innovative models – U.S. examples

– Information and new communication technology• Opportunities to learn from country initiatives

3Patient-Centered Care and Care Systems: Primary Care Foundation Connected to Care System

4Recent International Surveys in Eleven Countries

• 2013: General population– Access, cost, insurance complexity, country views

• 2012: Primary care doctors• 2011: “Sicker” adults (recent hospital stay, surgery,

illness, fair/poor health)– Coordination, communication, chronic disease

• Eleven Countries:– Australia, Canada, France, Germany, Netherlands,

New Zealand, Norway, Sweden, Switzerland, U.K., and United States

• Australia BHI partner/co-fund expanded NSW survey

5

Insights from Patients’ and Doctors’ Experiences

• Access and affordability– Insurance design matters

• Coordination a shared concern• Enhanced primary care makes a positive

difference• Country differences often linked to

underlying policies

66Overall Views of Health Care System, 2013

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries

USFR

CANGERSWENOR

NZAUS

NETHSWIZ

UK

0% 25% 50% 75% 100%

25404242444647485154

63

4849

50484642

4543

4440

33

2711

81010

1289

574

Works well, only minor change Fundamental change Completely rebuild

Percent

77

UK

SWE

NOR

CAN

SWIZ

GER

AUS FR NZ

NETH US

0

10

20

30

40

50

4 610

13 13 15 16 1821 22

37

27

Experienced a Cost-Related Access Problemin the Past Year, 2013

Percent*

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.* Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.

US Insured

88Out-of-Pocket Costs and Problems Paying Medical Bills

in the Past Year, 2013

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries

0

10

20

30

40

50

2 37 7 9 11

1417

24 25

41

Spent US$1,000 or more out-of-pocket

Had Serious Problems Paying or Unable to Pay Medical Bills

UKSW

ENO

RCA

NGE

RAU

SNE

TH NZSW

IZ FR US

14 6 7 7 8 9 10 10

13

23

99

GER NZ

NETH AU

SSW

E FRNO

R UK US CAN

0

25

50

75

100

76 7263 58 58 57 52 52 48

41

Access to Doctor or Nurse When Sickor Needed Care, 2013

Percent

NZ AUS

NETH

GER FR UK

SWE US

NOR

CAN

514 14 15 16 16

22 26 28 33

Same-day or next-day appointment

Waited six days or morefor appointment

Note: Question asked differently in Switzerland.

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries

10

UK GER

NETH NZ

SWIZ

AUS US CAN FR

SWE

0

20

40

60

80

100

6956 56 54 49 46

39 38 36 35

Access to After-Hours Care

Percent95 95 90 90

81 78 7668

4635

Adults, 2013Easy getting after-hours care

without going to the ER

Primary care physicians, 2012Practice has arrangement for

patients’ after-hours care to see doctor or nurse

Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys

Base: Needed care after hours.

11

AUS GER NETH UK NZ NOR SWIZ FR SWE US CAN0

25

50

75

22 22 24 27 28 28 28 31 3239 41

48

Used Emergency DepartmentPast Two Years, 2013

Percent

US Uninsured

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries

1212

SWIZ UK US

NETH

GER NZ

SWE

AUS FR

NOR

CAN

0

25

50

75

100

80 80 76 75 7259 54 51 51 46

39

Wait Times for Specialist Appointment

Percent

3 3 6 7 1017 18 18 19

26 29

Less than four weeks Two months or more

Base: Needed to see specialist in the past two years.Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Patients: Report problems with insurance complexity*

Insurance Complexity & Restrictions Concerns for Patients and Doctors

SWE UK NZ

NOR

CAN

AUS

GER

NETH FR

SWIZ US

0

30

60

4 4 7 815 16 17 19

23 2532

Percent

UK AUS

NOR

SWE NZ FR

CAN

SWIZ

NETH

GER US

10 11 12 1218 20 23 24

28

41

54

Primary care doctors:Insurance care restrictions pose

major time concern**

Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys

* 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.

13

14

Engaging Patients and Care Coordination

Patient Engagement in Care Management for Chronic Condition, 2011

Percent reported professional in past year has:

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Discussed your main goals/ priorities

63 67 42 59 67 62 51 36 81 78 76

Helped make treatment plan you could carry out in daily life

61 63 53 49 52 58 41 40 74 80 71

Given clear instructions on symptoms and when to seek care

66 66 56 64 64 63 44 49 84 80 75

Yes to all three 48 49 30 41 42 45 23 22 67 69 58

15

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven CountriesBase: Has chronic condition.

16

Sicker Adults: Coordination Gaps, 2011

UK SWIZ NZ AUS NETH SWE CAN US NOR FR GER0

20

40

60

80

20 2330

36 37 39 40 42 4353 56

Percent had any gap in past 2 years*

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries

* 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.

17

UK US SWIZ CAN NZ AUS GER NETH SWE NOR FR0

20

40

60

80

100

26 29

48 50 51 55 61 66 67 71 73

Percent any gap in past two years*

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries

* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.

Gaps in Hospital or Surgery Discharge Planning, 2011

18Transforming Primary CarePatient-centered teams and Care Systems

• Patients receive enhanced access to primary care, well coordinated by a team

• Patients actively engaged (treatment decisions, care at home)

• Teams use decision-support tools, assess performance with payment support

• Linked to care continuum – care system; health focus

2020 Vision Accessible

Patient Centered Coordinated Care

19

Patients with a Regular Doctor vs. Medical Home, 2011

UK SWIZ NZ US NOR FR AUS CAN GER NETH SWE0

20

40

60

80

100 99 99 9991

99 99 97 96 97 100 95

74 70 6556 53 52 51 49 48 48

33

Has a regular doctor or place of careHas a medical home

Percent

Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries

20

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US0

20

40

60

80

100

7970

59

7265

76

36

55

82 79 80

52

38 4050

4045

1828

51 54

41

Medical home No medical homePercent reporting positive patient-doctor relationship and communication*

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries

Patient-Doctor Communication, by Medical Home, 2011

Base: Has a regular doctor/place of care.

* 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.

Patient Engagement in Care Management for Chronic Condition, by Medical Home, 2011

21

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Base: Has chronic condition.

Percent reporting positive patient engagement in managing chronic condition*

* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US0

20

40

60

80

100

56 59

34

4754 51

29 32

73 7667

38 38

2433 29 27

16 15

5146 45

Medical home No medical home

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US0

20

40

60

80

100

31 30

49 53

3225

36 32

2015

3341

4957 59

42 4151

42

30 33

54

Medical home No medical home

22Experienced Coordination Gaps in Past Two Years,

by Medical Home, 2011Percent*

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

* 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.

23Hospital or Surgery Discharge Planning Gap

by Medical Home, 2011

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries

* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US0

20

40

60

80

100

4943

6660 59

42

6459

41

17 19

6357

82

6374

6878

70 67

5346

Medical home No medical homePercent*

24

Source: 2011 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, 2011

* Reported medical mistake, medication error, and/or lab test error or delay in past two years.

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US0

10

20

30

40

15 15

10

15 1619

22

16

6 6

17

2327

1518

23

29 29

22

15 14

29

Medical home No medical homePercent*

25Patient-Centered, Coordinated Primary Care Medical Homes as Part of Systems Approach

• Systems approach: Access, Quality, Efficiency• Primary care/care systems across care continuum

– Timely access to care: multiple points of access– Patient engagement in care– Information systems: quality & coordination– Routine feedback of patient and clinical outcomes– Coordinated care, creative use of teams– Incentives and system support to improve/innovate

Approach to redesigning primary care - systems– Part of “system” of care the aims to organize care

around patients and focus on outcomes

Community Care of North Carolina

Multiple Models of Care Systems and Teamwork26

27Enhanced Primary Care/Care Systems: Cost and Quality Outcomes

Geisinger Health System (Pennsylvania)• 18% reduction in all-cause hospital admissions; 36% lower readmissions• 7% total medical cost savings Mass General High-Cost Medicare Chronic Care Demo (Massachusetts)• 20% lower hospital admissions; 25% lower ED use; 7% net savings annual• Mortality-decline: 16% compared to 20% in control groupGuided Care - Geriatric Patients (Baltimore, Maryland-Washington, DC, area)Among patients in an integrated care delivery system: • 47% reduction in skilled-nursing facility admissions • 52% reduction in skilled-nursing facility daysGroup Health Cooperative of Puget Sound (Seattle, Washington)• 29% reduction in ER visits; 11% reduction ambulatory sensitive admissionsHealth Partners (Minnesota)• 29% decrease ED visits; 24% decrease hospital admissionsIntermountain Healthcare (Utah)• Lower mortality; 10% relative reduction in hospitalization• Highest $ savings for high-risk patients

Division of Population Health Management

Evidence based care improvement tactics

Milford, CE, Ferris TG (2012 Aug). A modified “golden rule” for health care organizations. Mayo Clin Proc. 87(8):717-720.

Longitudinal Care Episodic CarePrimary Care Specialty Care Hospital Care

Access to care

Patient portal/physician portal Access program

Extended hours/same day appointments Reduced low acuity admissions

Expand virtual visit options

Design of care

Defined process standards in priority conditions (multidisciplinary teams)

High risk care management

Shared decision making

Re-admissions

Hospital Acquired Conditions

100% preventive services Appropriateness Hand-off and

continuity programsChronic condition management

EHR with decision support and order entry

Measurement

Variance reporting/performance dashboardsQuality metrics: clinical outcomes, satisfaction

Incentive programs Costs/population Costs/episode

Pennsylvania: Geisinger Medical “Navigator” Home Sites and

Hospital Admissions/Readmissions

300325350375400425450

CY 2006 CY 2007

Medical Home Non-Medical Home

Source: Geisinger Health System, 2009. *Results reported in: R. Gilfillan et al, “Value and the Medical Home: Effects of Transformed Primary Care,” The American Journal of Managed Care, 16(8) 2010: 607-614.

Hospital admissions per 1,000 Medicare patients

• 18% reduction in hospital admissions• 36% reduction in hospital readmissions• 7% total medical cost savings

19.5

15.9

0

5

10

15

20

25

CY 2006 CY 2007

Readmission Rates for All Medical Home Sites

As of Q4-2008*:

30

Health IT FrameworkEvaluation Framework

Medical Home

Hospitals

Public Health Programs & Services

Community Health TeamNurse Coordinator

Social WorkersNutrition SpecialistsCommunity Health

WorkersMCAID Care Coordinators

Public Health Specialist

Specialty Care & Disease Management Programs

A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services

Multi Insurer Payment Reform that supports a foundation of medical homes and community health teams

A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry

An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact

Mental Health & Substance Abuse

Programs

Medical Home

Medical Home

Medical Home

Social, Economic, & Community

Services

Healthier Living Workshops

Vermont: Shared Resources Community Teams

INTERACT Collaborative Quality Improvement for Nursing Homes

Three strategies:• Identify, assess, and manage conditions to prevent

hospitalization• Document and communicate critical information• Improve advance care planning and develop palliative care

plansSource: J. G. Ouslander, G. Lamb, R. Tappen et al., "Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project," Journal of the American Geriatrics Society, April 2011.

Interventions to Reduce Acute Care Transfers (INTERACT) helps nursing-home staff manage residents’ health status

17-25% decline in hospital admissions in pilot

Spreading to 400+ homes

31

32

Creative Use of Informationand Communication Technology

33

Robert Kahn Cincinnati Children’s Hospital System Presentation to Commonwealth Fund Board of Directors , April 2012

County neighborhoods

Variation in Asthma Admission Rates within a Single County, Cincinnati,OH

33

34

• Interdisciplinary teams; home and community care; transition care• Care and assist with navigating complex health care systems• Patient-centered: targets and customizes interventions• Strong health information technology and EHR; Support team• Positive results

• Improved primary care access; high quality and patient ratings• Reduce hospital admissions, readmissions, ER use (17 to 27%)• Links primary, specialist and long term care• Patient and family preferences

Visiting Nurse Service New York Health PlansPatient-Centered Care Teams for High-Cost Chronically Ill Medicare and Medicaid – Special Needs and Long Term Care

Summary of presentation by Carol Raphael, Pres and CEO, NY Visiting Nurse Assn., 6/2011

35

Telehealth & Electronic Communication

• Veteran’s Health Administration

• North Dakota Telepharmacy (rural)

• E-consults and referrals

―Mayo Clinic: Minnesota

―San Francisco General

―Group Health: Seattle

• Kaiser Permanente integrated system: web-access, e-visits, “real” time data

• U. Tennessee Memphis: specialist remote consultation (3 state region)

36

8.77

14.2717.94

26.93

51.65

45.68

26.0

19.9816.08

12.22

0

10

20

30

40

50

60

70

30-D

ay R

eadm

issi

on (%

)

Very Low Low Intermediate High Very High

Predicted Readmission Risk Category

Derivation SamplesValidation Samples

Parkland, Texas: An EMR model to predict 30-day readmission for heart failure using SES risk and clinical risk. Model includes: systolic and diastolic blood pressure, pulse, temperature, pH, BNP, PT/ INR, glucose, CK-MB, troponin, wbc, pCO2, BUN, sodium, creatinine, CK, bilirubin, albumin, age, history of depression, single, male, no. of home address changes, medicare, high risk census tract, cocaine use, missed clinic visit, used pharmacy, prior inpatient admissions, ED presentation time. C-statistic: Derivation: 0.73; Validation 0.69

Source: Ruben Amarasingham, MD, Parkland Health and Hospital System, Presentation to Commonwealth Fund on May 12, 2010, “Harnessing Electronic Medical Record Data to Reduce Readmissions.”

Hospital: Use of IT to Predict Risk and Marshal Resources, Including Transition Care/Discharge

37Health Care and Population Health: Digital Age Enables Dynamic System Redesign

• Whole system view– Gains in health and value if we use resources

creatively and productively– Teams (including virtual teams) with information– Beyond “facilities”: care continuum

• Strategic focus on key areas – Transforming primary care linked to care systems– Creative use of electronic health information and

digital technology– Shared resources

• Supportive Policies: Align Payment, Insurance Design and Regulations with Value

38

Payment Reform: Value

Keys to Better Care, Better Health, and Lower Costs

Information Systems

Teams and Care System Redesign

39For More Information, Including Survey Data Visit www.commonwealthfund.org