Why Not the Best? A High Performance Health System in Hawaii

1. Why Not the Best? A High Performance Health System in Hawaii Hawaii Uninsured Project Fall ForumOctober 23, 2006Anne GauthierSenior Policy DirectorThe Commonwealth Fundwww.cmwf.org

2. Presentation Overview • The Commission on a High Performance Health System • The National Landscape: How are States Performing Compared to Achievable Benchmarks • State Efforts to Improve Performance • Legislative Proposals • Moving Forward

3. The Commonwealth Fund Commission on a High Performance Health System Objective: • Move the U.S. toward a higher-performing health care system that achieves better access, improved quality, and greater efficiency, with particular focus on the most vulnerable due to income, gaps in insurance coverage, race/ethnicity, health, or age The Commission is made up of 19 Commission members who come with divers practical and policy expertise in health care delivery, financing, and access and quality improvement.

4. Major Commission Products • Framework Statement (August 2006) • Provides sense of urgency to transform U.S. health care • Defines “systemness” and stresses need to achieve it • Depicts major sources of current system failures • Delineates roles for public and private sectors • Scorecard Report (September 2006) • Compares U.S. national average with the best achieved benchmarks across arenas of quality, access, efficiency, and equity • Provides a mechanism for monitoring change over time • Provides a yardstick against which to assess the effects of existing or proposed policies to improve performance • The framework and scorecard reports are aligned in using the same dimensions of high performance

5. QUALITY • Getting the right care • Coordinated care • Safe care • Patient-centered care ACCESS • Universal participation • Affordable • Equitable Commission Conception of High Performing Health System LONG, HEALTHY, AND PRODUCTIVE LIVES EFFICIENCY SYSTEM CAPACITY TO IMPROVE

6. Achieving a High Performance Health System Requires: • Committing to a clear national strategy and establishing a process to implement and refine that strategy • Delivering care through models that emphasize coordination and integration • Establishing and tracking metrics for health outcomes, quality of care, access, disparities, and efficiency

7. The National Landscape:How are States Performing Compared to Achievable Benchmarks? C F A D

8. Scorecard on US Health System • The U.S. falls far short on each of the core goals for health system performance relative to benchmarks • The US average ratio score is 66 across health outcomes, quality, access, equity, and efficiency • There are wide gaps across key indicators on benchmarks largely drawn from achieved rates • The consequence is needlessly lost lives, wasted health care expenditures, and lower economic productivity • $50 to $100 Billion annual savings and 100,000 to 150,000 lives • $130 billion in potential productivity gains from insuring the uninsured (IOM estimate) • Given that the US spends more than any other country, we should expect to lead on access, quality and efficiency • Benchmarks provide targets for improvement • With cost and coverage vital signs moving in the wrong direction, moving to a high performance system is of great urgency to secure a healthy nation

9. LONG, HEALTHY & PRODUCTIVE LIVES Mortality Amenable to Health Care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care. Deaths per 100,000 population* International Variation, 1998 State Variation, 2002 Percentiles * Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease DATA: International: WHO mortality database from Nolte and McKee 2003; U.S. 2002 state estimates: K. Hempstead, Rutgers University using Nolte/ McKee methodology. Methods in technical appendix to Scorecard Chartpack. SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

10. LONG, HEALTHY & PRODUCTIVE LIVES Infant Mortality Rate, 2002 Infant deaths per 1,000 live births International variation State variation * 2001. Data: International estimates—OECD Health Data 2005; State estimates—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2005a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

11. WA NH ME VT MT ND MN OR WI NY MA ID SD MI RI WY CT PA NJ IA OH NE DE NV IN IL MD WV UT VA CO DC CA KS MO KY NC TN OK AR SC NM AZ AL GA MS TX LA FL AK States Vary In Quality of Care 2000–2001 Quartile Rank First Second Third Fourth Note: State ranking based on 22 Medicare performance measures. Source: S.F. Jencks, E.D. Huff, and T. Cuerdon, “Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998–1999 to 2000–2001,” Journal of the American Medical Association 289, no. 3 (Jan. 15, 2003): 305–312.

12. QUALITY: THE RIGHT CARE Preventive Care Visits for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003 Percent of children (ages <18)received BOTH a medical and dental preventive care visit in past year Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

13. QUALITY: COORDINATED CARE Nursing Homes: Hospital Admission and Readmission RatesAmong Nursing Home Residents, by State, 2000 Hospitalization rates Re-hospitalization rate (within 3 months of nursing home admission) Percent Percent Data: V. Mor, Brown University analysis of Medicare enrollment data and Part A claims data for all Medicare beneficiaries who entered a nursing home and had a Minimum Data Set assessment during 2000. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 13

14. QUALITY: SAFE CARE Pressure Sores Among High-Risk and Short-Stay Residents in Nursing Facilities Percent of nursing home residents with pressure sores State distribution, 2004 By race/ethnicity, 2003 High-risk residents Short-stay residents Data: Nursing Home Minimum Data Set (AHRQ 2005a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

15. ACCESS: UNIVERSAL PARTICIPATION Percent of Adults Ages 18–64 Uninsured by State 1999–2000 2004–2005 NH NH ME WA NH VT ME WA VT ND MT ND MT MN MN OR NY MA WI OR MA NY ID SD WI RI MI ID SD RI WY MI CT PA WY NJ PA IA NJ CT NE IA OH DE IN NE OH NV DE IN IL MD NV WV UT VA IL MD CO DC WV UT VA KS MO KY CA CO DC KS MO KY CA NC NC TN TN OK SC AR OK AZ NM SC AR AZ NM MS GA AL MS GA AL TX LA TX LA FL FL AK AK 23% or more HI HI 19%–22.9% 14%–18.9% Less than 14% Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

16. States with Highest and LowestAdjusted Health Plan Premiums, 2002Employee-only adjusted premiums Dollars Adapted from J. Gabel, R. McDevitt, L. Gandolfo et al., “Generosity and Adjusted Premiums in Job-Based Insurance: Hawaii Is Up, Wyoming Is Down,” Health Affairs, May/June 2006 25(3):832–43.

17. EFFICIENCY Medicare Hospital 30-Day Readmission Rates, by Regions, 2003 Rate of hospital readmission within 30 days Percentiles Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2003 Medicare Standard Analytical Files 5% Inpatient Data SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

18. QUALITY: COORDINATED CARE Children with a Medical Home, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance Percent of children who have a personal doctor or nurse and receive care that is accessible, comprehensive, culturally sensitive, and coordinated* * Child had 1+ preventive visit in past year; access to specialty care; personal doctor/nurse who usually/always spent enough time and communicated clearly, provided telephone advice or urgent care and followed up after the child’s specialty care visits. Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

19. EQUITY: THE RIGHT CARE Receipt of All Three Recommended Services for Diabetics,by Race/Ethnicity, Family Income, Insurance, and Residence, 2002 Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year * ** * Insurance for people ages 18–64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants. Data: Medical Expenditure Panel Survey (AHRQ 2005a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

20. What are States Doing to Transform Health System Performance? ? C F A D

21. Keys to Transforming the U.S. Health Care System • Guarantee affordable health care coverage • Implement major quality and safety improvements • Work toward a more organized delivery system that emphasizes patient-centered primary and preventive care • Increase transparency and reporting on quality and costs • Expand the use of interoperable information technology • Reward performance for quality and efficiency • Encourage public-private collaboration

22. State Efforts to Guarantee Affordable Health Insurance Coverage 1. Guarantee Affordable Health Insurance Coverage

23. Hawaii Employer Mandate • Prepaid Health Care Act of 1974 requires all private-sector employers to provide health insurance to full-time employees • Only state to implement an employer mandate

24. Massachusetts Health Plan • MassHealth expansion for children up to 300% FPL; adults up to 100% poverty • Individual mandate, with affordability provision; subsidies between 100% and 300% of poverty • Employers must offer Section 125 Flex Accounts • Employer mandatory offer, employee mandatory take-up • Employer assessment ($295 if employer doesn’t provide health insurance) • Connector to organize affordable insurance offerings through a group pool Source: John Holahan, “The Basics of Massachusetts Health Reform,” Presentation to United Hospital Fund, April 2006.

25. Massachusetts Strategies for Coverage: Everyone “does their part” Government Health Care System • Subsidized insurance • The Connector • Uncompensated Care pool reform • Meet quality and performance standards • New levels of “transparency” • Adjust to payment changes Expanded Coverage Employers Individuals • Fair Share Assessment • “Free Rider” provisions • Mandatory “cafeteria plans” • Individual Mandate Source: Lischko, Amy. October 16, 2006. “Massachusetts Health Reform.” NASHP 19th Annual State Health Policy Conference, Pittsburgh, PA.

26. Retaining and Expanding Employer Participation: Maine’s Dirigo Health Annual expenditures on deductible and premium $2,738 • New insurance product; $1250 deductible; sliding scale deductibles and premiums below 300% poverty • Employers pay fee covering 60% of worker premium • Began Jan 2005; Enrollment 14,700 as of 4/30/06 $2,188 $1,638 $1,100 $550 $0 * After discount and employer payment (for illustrative purposes only).

27. Coverage expansion Catamount Health Plans Targets individuals w/o access to work-based coverage Premium subsidies based on sliding scale up to 300% FPL Comprehensive benefit package including primary care, chronic care, acute care & other services No patient cost-sharing for preventive or chronic care services Builds upon Wagner’s Chronic Care Model Financing Employer assessment Increase in tobacco taxes Federal matching funds from Medicaid waiver Vermont Health Care Affordability Act Enacted May 2006

28. Illinois All-Kids • Effective July 1, 2006 • Available to any child uninsured for 6 months or more • Cost to family determined on a sliding scale • Linked to other public programs - FamilyCare & KidCare • Funded by federal and state funds • Children <200% of the federal poverty level funded by federal funds • Children 200%+ of the federal poverty level funded by state savings from the Medicaid Primary Care Case Management Program • All-Kids Training Tour • Public outreach program to highlight new and expanded healthcare programs

29. New Jersey Raises Age of Dependent Status for Health Insurance Millions uninsured, adults ages 19–29 • As of 5/2006, NJ requires all state insurers to raise dependent age limit to 30 • Highest age limit in country • Covers uninsured, unmarried adults with no dependents who are either NJ residents or full-time students • Premium capped at 102% of amount paid for dependent’s coverage prior to aging out • 200,000 young adults expected to receive coverage under the law Source: S.R. Collins, C. Schoen, J.L. Kriss, M.M. Doty, B. Mahato, “Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help,” Commonwealth Fund issue brief, May 2006. (Analysis of the March 2001–2005 Current Population Surveys)

30. Implement Major Quality and Safety Improvements 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements

31. Puget Sound Health Alliance • Regional partnership involving employers, physicians, hospitals, patients, health plans • Working to promote evidence-based medicine throughout King County, Washington • Participants agree to use evidence to identify and measure quality health care, then produce publicly-available comparison reports designed to help improve health care decision-making

32. Work Toward a More Organized Delivery System that Emphasizes Patient-Centered Primary and Preventive Care 3. Emphasize Patient-Centered Primary, and Preventive Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements

33. Utah’s Primary Care Network Section 1115 Medicaid Waiver • Targets uninsured adults (19–54) with family income less than 150% FPL • Provides primary care and preventive care services • Physician office visits • Immunizations • Emergency care • Lab, X-ray, medical equipment & supplies • Basic dental care • Hearing & vision screening • Prescription drugs • Hospitals provide $10 million in charity care for PCN participants

34. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 4. Increase Transparency and Reporting on Quality and Costs

35. Wisconsin Collaborative for Healthcare Quality Voluntary consortium formed in 2003 -- physician groups, hospitals, health plans, employers & labor Develops & publicly reports comparative performance information on physician practices, hospitals & health plans Includes measures assessing ambulatory care, IT capacity, patient satisfaction & access Wisconsin Health Information Organization Coalition formed in 2005 to create a centralized health data repository based on voluntary sharing of private health insurance claims, including pharmacy & laboratory data Wisconsin Dept of Health & Family Services and Dept of Employee Trust Funds will add data on costs of publicly paid health care through Medicaid Wisconsin

36. Expand the Use of Interoperable Information Technology 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs

37. Information Exchange:States Leading the Way • New York State Health Information Technology (HIT) initiative • Under the Health Care Efficiency and Affordability Law for New Yorkers, $52.9 million awarded to 26 regional health networks to expand technology in NY health care system and support clinical data exchange; Commonwealth Fund-supported evaluation underway Source: Evolution of State Health Information Exchange, AHRQ, Publication No. 06-0057, January 2006.

38. Reward Performance for Quality and Efficiency 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs 6. Reward Performance for Quality and Efficiency

39. Building Quality Into RIte CareHigher Quality and Improved Cost Trends Cumulative Health Insurance Cost Trend Comparison Percent • Quality targets and $ incentives • Improved access, medical home • One third reduction in hospital and ER • Tripled primary care doctors • Doubled clinic visits • Significant improvements in prenatal care, birth spacing, lead paint, infant mortality, preventive care RI Commercial Trend RIte Care Trend Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003.Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005.

40. Encourage Public-Private Collaborationto Achieve Simplification, More Effective Change 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs 6. Reward Performance for Quality and Efficiency

41. Initiated in 2004 – alliance between state, private businesses & labor groups Purchase health insurance for 70% of state residents ~3.5 million people Pool purchasing power to drive value in health care delivery system Set uniform performance standards, cost/quality reporting requirements & technology demands Four key strategies: 1. Reward or require “best in class” certification 2. Adopt and utilize uniform measures of quality and results 3. Empower consumers with easy access to information 4. Require use of information technology Minnesota Smart-Buy Alliance

42. Expanding Coverage is Only One Piece of the Puzzle 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs 6. Reward Performance for Quality and Efficiency

43. Maine, Maine and Vermont have quality initiatives built into coverage expansions Maine Created Maine Quality Forum to advocate for high quality health care and help each Maine citizen make informed health care choices. Massachusetts Cost and Quality Council formed Vermont Quality improvement initiatives Public-private collaboration Collection of health care data from all payers Provides rules to publicly report price & quality information Several States Attempting Comprehensive Health Reform

44. 5 point strategy Creating affordable health plans for small businesses & individuals Increasing wellness programs Investing in health care technology Developing centers of excellence Leveraging the state’s purchasing power RI Quality Institute Non-profit coalition including hospitals, providers, insurers, consumers, business, academia & government Partnered with “SureScripts” to implement state-wide electronic connectivity between all retail pharmacies and prescribers in the state Health Information Exchange Initiative Statewide public/private effort AHRQ contract 5 yr/ $5M Connecting information from physicians, hospitals, labs, imaging & other community providers Rhode Island:Five-Point Strategy

45. National Legislative Proposals to Facilitate State Innovations

46. H.R. 5684: Health Partnership Through Creative Federalism Act Rep. Tammy Baldwin (D-WI) Rep. Tom Price (R-GA) • Real cooperation from across the aisle – proposed by Baldwin and Price with the support of both the Heritage Foundation and the Brookings Institute; National Governor’s Association also had role in drafting the bill • Requests that states submit proposals for state health care coverage expansion and improvements in quality, efficiency, cost-effectiveness, and the appropriate use of health information technology • State proposals defined as statewide, multi-state or limited to certain regions • Establishes a Commission to: • Request and review proposals and submit a list it recommends for approval to Congress • Report to the public concerning progress made by states • Make recommendations for minimizing negative effects of state programs on national employer, provider organizations, insurer

47. S. 2772: Health Partnership Act • Provides states with grants to carry out innovative state health programs, with priority given to programs most likely to expand coverage and improve access • Establishes a Commission to: • provide states with reform options for state health care expansion and improvement programs • establish minimum performance measures and goals with respect to coverage, quality, and cost of state programs • review state applications and determine whether to submit a state proposal to Congress Senator George Voinovich (D-WI) Senator Jeff Bingaman (D-NM)

48. Moving Forward States Can Lead the Way

49. What States Can Do to Promote a High Performance Health System: Strategies to Expand Coverage • Design shared responsibility strategy to include state, employers and individuals • Expand public programs • Provide financial assistance to low income workers and employers to afford coverage • Require employers to offer Section 125 benefit plans • Mandate individuals to purchase coverage • Require employers to offer and employees to take up insurance • Require insurers to raise age limit for dependents • Pool purchasing power and promote new benefit designs to make coverage more affordable • Develop reinsurance programs to make coverage more affordable in the small group and individual markets

50. What States Can Do to Promote a High Performance Health System: Strategies to Improve Quality and Efficiency • Promote evidence-based medicine • Promote effective chronic care management • Promote transitional care post-hospital discharge • Encourage data transparency and reporting on performance • Promote/practice value-based purchasing • Promote the use of health information technology • Promote wellness and healthy living • Encourage selection of medical home and improved access to primary care and preventive services • Simplify and streamline public program eligibility and re-determination