THE COMMONWEALTH FUND Figure 1. Annual Increases in Physician Fees and Figure 1. Annual Increases in Physician Fees and SGR-Related Expenditures Per Fee-for-Service SGR-Related Expenditures Per Fee-for-Service Beneficiary, 1998-2005 Beneficiary, 1998-2005 -3 .8 5.9 -0 .6 0.1 1.4 4.5 4.9 2.2 2.1 8.2 10.0 7.7 4.0 1 0.8 9.3 3.8 -6 -4 -2 0 2 4 6 8 10 12 Fees SG R -relate d expenditures per fee-for-service beneficia ry Source: Letter to Glenn M. Hackbarth, Chair, Medicare Payment Advisory Commission, from Herb B. Kuhn, Director, Center for Medicare Management, Centers for Medicare and Medicaid Services, dated April 7, 2006. Year Percent change 1998 1999 2000 2001 2002 2003 2004 2005
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THE COMMONWEALTH
FUND
Figure 1. Annual Increases in Physician Fees and Figure 1. Annual Increases in Physician Fees and SGR-Related Expenditures Per Fee-for-Service Beneficiary, 1998-SGR-Related Expenditures Per Fee-for-Service Beneficiary, 1998-
20052005
-3.8
5.9
-0.6
0.11.4
4.54.9
2.22.1
8.2
10.0
7.7
4.0
10.8
9.3
3.8
-6
-4
-2
0
2
4
6
8
10
12
Fees SGR-related expenditures per fee-for-service beneficiary
Source: Letter to Glenn M. Hackbarth, Chair, Medicare Payment Advisory Commission, from Herb B. Kuhn, Director, Center for Medicare Management, Centers for Medicare and Medicaid Services, dated April 7, 2006.
Year
Perc
ent
change
1998 1999 2000 2001 2002 2003 2004 2005
THE COMMONWEALTH
FUND
Figure 2. Annual Rates of Increase in Physician Fees and SGR-Figure 2. Annual Rates of Increase in Physician Fees and SGR-Related Expenditures Per Fee-for-Service Beneficiary, 1997-Related Expenditures Per Fee-for-Service Beneficiary, 1997-
2001 and 2001-20052001 and 2001-2005
3.4
-0.7
7.4 7.4
-2
-1
0
1
2
3
4
5
6
7
8
Fees SGR-related expenditures per fee-for-service beneficiary
1997-2001 2001-2005
Period
Annual Perc
ent
Change
Source: Letter to Glenn M. Hackbarth, Chair, Medicare Payment Advisory Commission, from Herb B. Kuhn, Director, Center for Medicare Management, Centers for Medicare and Medicaid Services, dated April 7, 2006.
THE COMMONWEALTH
FUND
Figure 3. Medicare Part B Premium (Monthly), Figure 3. Medicare Part B Premium (Monthly), 1998-2006 (Actual) and 2007-2015 (Projected)1998-2006 (Actual) and 2007-2015 (Projected)
0
20
40
60
80
100
120
140
Part B Premium
Year
Source: Board of Trustees, Federal HI and Federal SMI Trust Funds, 2006 Annual Report.
43.80
88.50
122.40
THE COMMONWEALTH
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Figure 4. Profile of Medicare Elderly Beneficiaries and Figure 4. Profile of Medicare Elderly Beneficiaries and Employer Coverage Nonelderly, Employer Coverage Nonelderly,
by Poverty and Health Status, 2003by Poverty and Health Status, 2003
No health problems, higher income
15%Health problems,
lower income38%
Note: Respondents with undesignated poverty were not included; lower income defined as <200% of poverty; health problems defined as fair or poor health, any chronic condition (cancer, diabetes, heart attack/disease, and arthritis), or disability .
Source: The Commonwealth Fund Biennial Health Insurance Survey (2003).
Health problems, higher income
40%
No health problems, lower income
8%
No health problems, higher income
56%
Health problems, lower income
7%
Health problems, higher income
24%
No health problems, lower income
14%
Medicare, Ages 65+ Employer, Ages 19–64
THE COMMONWEALTH
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Figure 5. Projected Out-of-Pocket Spending As a Share of Income Figure 5. Projected Out-of-Pocket Spending As a Share of Income Among Groups of Medicare Beneficiaries, Among Groups of Medicare Beneficiaries,
2000 and 20052000 and 2005
21.7
44.0
29.1
8.9
51.6
29.9
63.3
41.1
7.8
71.8
0
20
40
60
80
Beneficiaries age 65+ Beneficiairies withphysicial or cognitivehealth problems and
no other healthinsurance
Disabled beneficiariesages 45–65
Beneficiaries ages65–74 with high
incomes*
Female beneficiariesage 85+ with physical
or cognitive healthproblems and low
incomes^
2000 2025
Source: S. Maxwell, M. Moon, and M. Segal, Growth in Medicare and Out-of-Pocket Spending: Impact on Vulnerable Beneficiaries, The Commonwealth Fund, January 2001 as reported in R. Friedland and L. Summer, Demography Is Not Destiny, Revisited, The Commonwealth Fund, March 2005..
Out-of-pocket spending as percent of income
* Annual household incomes of $50,000 or more.
^ Annual household incomes of $5,000 to $20,000.
THE COMMONWEALTH
FUND
Figure 6. Access to Physicians for Medicare Figure 6. Access to Physicians for Medicare Beneficiaries and Privately Insured People, 2005Beneficiaries and Privately Insured People, 2005
7483
75
89
6775 75
86
0102030405060708090
100
Routine Care Illness or
Injury
Primary care Spec ialist
Medicare Privately InsuredPercent
Never had a delay to appointment
No problem finding physician
Source: MedPAC Report to the Congress: Medicare Payment Policy, March 2006, p. 85.
THE COMMONWEALTH
FUND
Figure 7. Proportion of Recommended Care Received Figure 7. Proportion of Recommended Care Received by U.S. Adults, by Selected Conditionsby U.S. Adults, by Selected Conditions
Source: McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,” The New England Journal of Medicine (June 26, 2003): 2635–2645.
55
7665
54
39
23
0
20
40
60
80
100
Overall Breast Cancer Hypertension Asthma Pneumonia Hip Fracture
Percent of recommended care received
THE COMMONWEALTH
FUND
Figure 8. Life Expectancy at Age 65Figure 8. Life Expectancy at Age 65
19.6 19.119.519.620.020.621.021.323.0
16.116.616.016.116.717.217.616.918.0
0
5
10
15
20
25
J apan (2003)
France (2001)
Australia (2003)
Canada (2002)
New Zealand (2002)
OECD Median (2002)
Germany (2001)
United States (2002)
United K ingdom (2002)
Female Male
Source: OECD Health Data, 2005.
THE COMMONWEALTH
FUND
Figure 9. Patient Reported Medical Mistake,Figure 9. Patient Reported Medical Mistake,Medication Error, or Test Error in Past 2 YearsMedication Error, or Test Error in Past 2 Years
Percent
Source: 2005 Commonwealth Fund International Health Policy Survey.
2730
2325
22
34
0
25
50
AUS CAN GER NZ UK US
THE COMMONWEALTH
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Figure 10. Interpersonal Quality of Care Is LackingFigure 10. Interpersonal Quality of Care Is Lacking
56 59 59
46
6559
66
54
0
20
40
60
80
100
Health providers
always listened
carefully
Health providers
always explained
things c learly
Health providers
always showed
respect
Health providers
always spent
enough time
Source: S. Leatherman and D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005, The Commonwealth Fund. www.cmwf.org; Medical Expenditure Panel Survey (AHRQ 2005).
Percent of community-dwelling adultsin 2001 who visited doctor's office in past year
Ages 45–64 Age 65+
THE COMMONWEALTH
FUND
Figure 11. Communication With PhysiciansFigure 11. Communication With PhysiciansViews of Sicker AdultsViews of Sicker Adults
In the past 2 years: AUS CAN NZ UK US
Left a doctor’s office without getting important questions answered
21 25 20 19 31
Did not follow a doctor’s advice
31 31 27 21 39
Source: 2002 Commonwealth Fund International Health Policy Survey.
THE COMMONWEALTH
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Figure 12. Deficiencies in Care CoordinationFigure 12. Deficiencies in Care Coordination
Percent saying in the past 2 years:
AUS CAN GER NZ UK US
Test results or records not available at time of appointment
12 19 11 16 16 23
Duplicate tests: doctor ordered test that had already been done
11 10 20 9 6 18
Percent who experienced either coordination problem
19 24 26 21 19 33
Source: 2005 Commonwealth Fund International Health Policy Survey. Adults with Health Problems.
THE COMMONWEALTH
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Figure 13. Continuity of Care with Same PhysicianFigure 13. Continuity of Care with Same Physician
Source: 2005 Commonwealth Fund International Health Policy Survey. Adults with Health Problems.
Percent: AUS CAN GER NZ UK US
Has regular doctor 92 92 97 94 96 84
--5 years or more 56 60 76 57 66 42
No regular doctor 8 8 3 6 4 16
THE COMMONWEALTH
FUND
Figure 14. Coordination Problems byFigure 14. Coordination Problems byNumber of DoctorsNumber of Doctors
Percent
Source: C. Schoen et al., “Taking the Pulse: Experiences of Patients with Health Problems in Six Countries,” Health Affairs Web Exclusive (November 3, 2005). Based on the 2005 Commonwealth Fund International Health Policy Survey.
15 16
711
22 2327
31 3026
43
30
0
25
50
75
AUS CAN NZ UK US GER
1 Doctor 4 or more Doctors
*Either records/results did not reach doctors office in time for appointment or doctors ordered a duplicate medical test
THE COMMONWEALTH
FUND
Figure 15. Two-Thirds of Medicare Spending is for
People With Five or More Chronic Conditions
5+ chronic conditions
66%
No chronic conditions
1%
4 chronic conditions
13%
1-2 chronic conditions
10%
3 chronic conditions
10%
Source: G. Anderson and J. Horvath, Chronic Conditions: Making the Case for Ongoing Care (Baltimore, MD: Partnership for Solutions, December 2002)
THE COMMONWEALTH
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87%
46%
57%
27%27%
59%
79%
14%
36%
68%
13%
25%
85%
61%
23%
35%37%
66%
84%77%
Electronic billing Access to test
results
Ordering* Electronic medical
records
All Physic ians
1 Physic ian
2-9 Physic ians
10-49 Physic ians
50+ Physic ians
Figure 16. Physician Use of Electronic Technology Figure 16. Physician Use of Electronic Technology Varies by ApplicationVaries by Application
* Electronic ordering of tests, procedures, or drugs.
Percent indicating "routine” or “occasional" use
Source: Commonwealth Fund 2003 National Survey of Physicians and Quality of Care.
THE COMMONWEALTH
FUND
Figure 17. Electronic Health Records (EHR) in Solo Figure 17. Electronic Health Records (EHR) in Solo or Small Group Practices: A Case Studyor Small Group Practices: A Case Study
43,826
14,462
63,600
11,8675,9578,412
010,00020,00030,00040,00050,00060,00070,000
Average per FTE
provider
Minimum Maximum
Initial costs Ongoing costs per provider per year
EHR Financial Costs Per FTE Provider For 14 Practices,
2004-2005
Source: R. Miller, et al. “The Value of Electronic Health Records in Solo or Small Group Practices. Health Affairs. 24(5). (September/October 2005): 1127.
Dollars
THE COMMONWEALTH
FUND
Figure 18. EHR Financial Benefits Per FTE Provider, For 14 Figure 18. EHR Financial Benefits Per FTE Provider, For 14 Solo/Small Group Practices, 2004-2005Solo/Small Group Practices, 2004-2005
32,737
16,929 15,808
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
Total benefits
per provider
Savings from
increased coding
levels
Efficiency
savings
Average per FTE provider ($)
Source: R. Miller, et al. “The Value of Electronic Health Records in Solo or Small Group Practices. Health Affairs. 24(5). (September/October 2005): 1127.
THE COMMONWEALTH
FUND
Figure 19. Variation in Per Capita Medicare Spending by Hospital Referral Region, 2000
Source: Eliot Fisher, presentation at AcademyHealth Annual Research Meeting, June 2006.
Average Annual Reimbursement per Beneficiary (Wage-Index Adjusted)
Av
era
ge
Qu
ali
ty o
f C
are
Sc
ore
Figure 20. Variation in Annual Total Cost and Figure 20. Variation in Annual Total Cost and Quality for Chronic Disease PatientsQuality for Chronic Disease Patients
Quality of Care* and Medicare Spending for Beneficiaries with Three Quality of Care* and Medicare Spending for Beneficiaries with Three Chronic Conditions, by Hospital Referral RegionChronic Conditions, by Hospital Referral Region
* Based on percent of beneficiaries with three conditions (diabetes, chronic obstructive pulmonary disease, and congestive heart failure) who had a doctor’s visit four weeks after hospitalization, a doctor’s visit every six months, annual cholesterol test, annual flu shot, annual eye exam, annual HbA1C test, and annual nephrology test. Source: G. Anderson and R. Herbert for The Commonwealth Fund, Medicare Standard Analytical File 5% 2001 data.
Best Practice Curve
Median Amount Spent per Patient per HRR = $28,694
AAGreenville, NCGreenville, NC
BB CC
DDNewark, NJNewark, NJ
Melrose Park, ILMelrose Park, ILSaginaw, MISaginaw, MI
Manhattan, NYManhattan, NY
Orange County, CAOrange County, CAEast Long Island, NYEast Long Island, NY
Ft. Lauderdale, FLFt. Lauderdale, FL
Boston, MABoston, MA
THE COMMONWEALTH
FUND
Mort
alit
y R
ate
of
Med
icare
Enro
llees
Mort
alit
y R
ate
of
Med
icare
Enro
llees
Figure 21. Medicare Spending Per Enrollee and Mortality Figure 21. Medicare Spending Per Enrollee and Mortality Rate by State, 2003Rate by State, 2003
Source: Data from The Dartmouth Atlas of Health Care, www.dartmouthatlas.org
2.5%
3.5%
4.5%
5.5%
6.5%
$4,500 $5,500 $6,500 $7,500 $8,500
Medicare Spending per EnrolleeMedicare Spending per Enrollee
HI
NDIA
OR
SDNMID
MT
MN
WYUT
NE
WIWA VA
VT
ME
AR
NH
INNC
SC
GA
MO
WVKS
AZ
CO
DC
KY
TN
AK
OH
ALMS
US
IL
DE
OK RI
MI
PA
NV
TX
FLMD
CT
CA
NY
LA
MA NJ
THE COMMONWEALTH
FUND
0
10
20
30
40
50
60
70
Electronic
prescribing
Electronic
check of Rx
interaction
Electronic
retrieval of
lab results
Electronic
access of
c linical
notes
Electronic
retrieval of
patient
reminders
2003 measurement year 2004 measurement yearPercent
Figure 22. IHA Trends in Point-of-Care TechnologyFigure 22. IHA Trends in Point-of-Care Technology
Source: Tom Williams, “California Pay for Performance (P4P): A Case Study.”
THE COMMONWEALTH
FUND
Figure 23. Evaluation of PacifiCareFigure 23. Evaluation of PacifiCarePay for Performance: Improvement in Pay for Performance: Improvement in
Cervical Cancer ScreeningCervical Cancer Screening
5.3
1.7
0
5
10
15
20
California Pacific Northwest
Source: M.B. Rosenthal et al., “Early Experience with Pay-for-Performance: From Concept to Practice,” JAMA 294, no. 14 (October 12, 2005): 1788-93.
Percent improvement in cervical cancer screening rates among physician groups
(Intervention group) (Control group)
THE COMMONWEALTH
FUND
Figure 24. Physicians Participating in theFigure 24. Physicians Participating in theDiabetic Care Program From 1997 to 2003Diabetic Care Program From 1997 to 2003
Showed Significant Improvement in PerformanceShowed Significant Improvement in Performance
1725
4546
0
50
100
1997 2003 1997 2003
Percent of patients reaching quality target
HgA1c < 7% LDL/Chol < 100mg/dL
Source: National Committee for Quality Assurance web site, www.ncqa.org/dprp.
THE COMMONWEALTH
FUND
14.813.6 13.1
11.6
15.4
0
5
10
15
20
Bottom
quality
quartile
26–50% 51–75% 76–90% Top quality
decile
Figure 25. Medicare Premier Hospital Demonstration: Higher Figure 25. Medicare Premier Hospital Demonstration: Higher Quality Hospitals Have Fewer ReadmissionsQuality Hospitals Have Fewer Readmissions
Readmission Rates by Pneumonia Quality Ranking (Percent)
Figure 26. Coordination Across Sites of Care:Figure 26. Coordination Across Sites of Care:Care Transition Measure Scores,* Emergency Care Transition Measure Scores,* Emergency Department Use, and Hospital ReadmissionsDepartment Use, and Hospital Readmissions
0
10
20
30
40
50
60
70
80
90
100
No Yes
* When I left the hospital, I had a good understanding of the things I was responsible for in managing my health; when I left the hospital, I clearly understood the purpose for taking each of my medications; The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.Source: E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The Commonwealth Fund Commission on a High Performance Health System, March 30, 2006.
0
10
20
30
40
50
60
70
80
90
100
No Yes
Emergency Department Use Hospital Readmissions
p=0.01 p=0.04
THE COMMONWEALTH
FUND
Figure 27. Improving Care Coordination andFigure 27. Improving Care Coordination andReducing CostReducing Cost
• Importance of improving transitions in care, doctor to doctor, and post-hospital
• Follow-up care following hospital discharge could reduce rehospitalization
• High cost care management could reduce errors and lower costs
• Will require restructuring Medicare benefits and incentives
Dollars
$9,618
$6,152
$8,809
$4,977
$1,175$809$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
Control Intervention
V is its Inpatient Care
Source: M.D. Naylor, Making the Bridge from Hospital to Home, The Commonwealth Fund, Fall 2003.
Effect of Advanced Practice Nurse Care on Congestive Heart Failure Patients’ Average Per Capita Expenditures
THE COMMONWEALTH
FUND
Figure 28. Improvement in Doctors’ Cervical Cancer Figure 28. Improvement in Doctors’ Cervical Cancer Screening Rates Compared to Bonus Payments After Screening Rates Compared to Bonus Payments After
Implementation of Quality Incentive ProgramImplementation of Quality Incentive Program
2.5
7.4
11.1
0
5
10
15
20
25
High
performing
group
Middle
performing
group
Low
performing
group
Source: M.B. Rosenthal et al., “Early Experience with Pay-for-Performance: From Concept to Practice,” JAMA 294, no. 14 (October 7, 2004): 1788-93.
437
128
27
0
100
200
300
400
500
High
performing
group
Middle
performing
group
Low
performing
group
Percent Thousands of dollars
Improvement in Screening Improvement in Screening RatesRates
Bonuses ReceivedBonuses Received
THE COMMONWEALTH
FUND
67
23
8 6
0
50
100 No, have not been involved Yes, a LOCAL effort
Yes, a REGIONAL effort Yes, a NATIONAL effort
Figure 29. Most Physicians Have Figure 29. Most Physicians Have NotNot Been Involved in Been Involved in Collaborative Efforts to Improve Quality of CareCollaborative Efforts to Improve Quality of Care
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
Percent indicating involvement in any collaborative efforts in past two years*
* Multiple answers possible.
Involved in at least one effort (32%)
THE COMMONWEALTH
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8%
11%
58%
80%
72%
72%
60%
8%
4%
19%
19%
14%
15%
28%
27%
Quality Bonus/Incentive Payments from
Insurance Plans
Patient Surveys/ Experience
Measures of Clinical Care
Board Re-Certification Status
Productivity/ Billing
Major Factor Minor Factor Not a Factor
Figure 30. Current Factors AffectingFigure 30. Current Factors AffectingPhysicians’ CompensationPhysicians’ Compensation
Source: The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care.
