The Commonwealth Fund Blog

National Leadership to Achieve a Performance-Driven Health System

July 8, 2009

Tags: Affordable Care Act health spending


Karen Davis Steve Schoenbaum By Karen Davis and Steve Schoenbaum

The elements of health reform Congress are considering are emerging as draft proposals from the key committees and as the Republican alternatives are released. What is largely missing from these proposals, however, is an overarching framework that establishes goals for a high-performance health system and includes a coordinated set of public policies and private sector actions that would ensure the U.S. reaches benchmark levels of health system performance by 2020. Without a mechanism for setting long-range goals as well as immediate priorities for performance improvement, we could fail to realize the enhanced impact and economies possible from concerted action.

Setting Health Goals and Priorities for Performance Improvement

The Commonwealth Fund’s Commission on a High Performance Health System has documented that the U.S. is not achieving the health outcomes, quality of care, and access to care that could be achieved with the resources the country commits to health care. The lack of accountability for results at the national, state, and local health care delivery levels reflects an absence of goals, priority improvement targets, incentives, and support required to meet performance targets—as well as the lack of consequences for performance that does not meet such targets.

A major reason for this lack of accountability, and for highly variable, often poor performance, is the fragmentation of the health care financing and delivery system. Decisions shaping the U.S. health care system are made by thousands of private and public stakeholders, largely acting independently and often with a goal of shifting costs to other parties rather than achieving the best results for the system as a whole. What is needed is national leadership to coordinate the now-disparate components of the health care system.

There are a number of national health initiatives with defined objectives, including the U.S. Department of Health and Human Services' "Healthy People 2010," the National Quality Forum’s "National Priorities Partnership," and the Institute of Medicine’s priorities for comparative effectiveness research. The Commonwealth Fund’s Commission on a High Performance Health System has developed and published a national scorecard on U.S. health system performance that includes achievable benchmarks across the domains of health outcomes, quality, access, equity, and efficiency.

Health reform proposals under consideration in the House and Senate include requirements for the development of national priorities for quality improvement and reports to Congress outlining national priorities and strategies for health care quality improvement. A Republican-sponsored alternative proposal calls for a new forum on the quality and effectiveness of health care, to be comprised of private sector representatives. But these proposals focus primarily on health care quality, falling short of a comprehensive set of goals for health system performance that includes access to care, equity, and efficiency. The U.S. health system will not reach its potential until we have an agreed-upon set of national performance goals and improvement targets with the government’s imprimatur, along with supporting policies, resources, and actions. One process for establishing these goals, targets, and supports could be an annual "Health Performance Report," submitted to Congress by the President. This publication would report on health system performance, including:

  • health outcomes across geographic regions of the U.S. and population subgroups;
  • access to care;
  • quality of care;
  • efficiency; and
  • capacity to innovate and improve.

Such a report would help create a clear picture of the state of the health system and complement the "Economic Report of the President" and data reports on economic growth and employment. Most important, it would include the President’s 2020 goals for health system performance, priority targets for improvement, and recommended policies and private sector actions required to meet them, all based on consultation with the public and health care stakeholders. Congress would act annually to accept and/ or modify these goals and priorities, and make the policy changes needed to help achieve them. The power of driving performance improvement through presidential, Congressional, and private sector leadership might best be understood by considering the illustrative health system performance goals for 2020 and target indicators for improvement outlined in the exhibit below. These examples highlight the many components of health system performance, which encompasses health outcomes, delivery system organization, quality and safety, disparities, insurance coverage, and incentives to bend the cost curve.

A Whole-System Strategy

Once agreement on the long-range goals and shorter-term improvement targets is achieved, the President could oversee the development of an implementation plan and submit it to Congress for review; the plans would be updated each year. The President also could ensure that the public agencies or private organizations responsible for the key components of a high-performance health system had a clear mandate based on the goals and targets, and would be held accountable for fulfilling that mandate. For example, the goals and targets would shape priorities within the following areas:

  • Comparative effectiveness. Priorities for the $1.1 billion allocated to various agencies within the U.S. Department of Health and Human Services by the American Recovery and Reinvestment Act for comparative-effectiveness research would be based on these goals and targets.
  • Health information technology. Meaningful use of health information technology and design of health information exchanges provided for under the American Recovery and Reinvestment Act would be consistent with achieving these goals and targets.
  • All-population/all-payer database. An all-population/all-payer data system would be developed and used to monitor and track performance on these goals and targets. Public reporting would be developed to ensure transparency and support improvement efforts.
  • Quality improvement. Professional bodies and state agencies that set standards for quality, accreditation, certification, and licensure of health care providers and organizations would agree to align their processes with actions to achieve these goals and targets.
  • Workforce planning and development. Public agencies charged with workforce planning and development would develop policies to address gaps in accessibility of services and in preparation of teams of health care professionals required to meet these goals and targets.
  • Public health. Achieving population-oriented health goals and the best possible health outcomes would become the guiding principle for investment in public health activities and adoption of policies such as taxing products related to unhealthy behaviors.
  • Insurance exchange. Health insurance exchanges or connectors at the national, state, or regional level would set standards for qualified health plans that would help meet these goals and targets.
  • Payment reform. Perhaps most important, Medicare, Medicaid, and private and public plans participating in health insurance exchanges would be held accountable for payment policies that reward providers based on these goals and targets. The design and rapid testing of new incentives would be facilitated by creation of a Medicare Payment Board within the executive branch whose decisions would be reviewed periodically by Congress.

Coordinating national leadership for all of these components of the health system would enable the federal government to: 1) assign clear responsibility and authority for the key aspects of the health system singly and jointly, and 2) provide the necessary capacity to enable agencies and organizations to act to secure access for all, better health outcomes, and slow the rate of cost growth. The new leadership roles needed to provide a coordinated and systemic approach to improving population health and wresting better value from health spending should be addressed as part of health reform legislation.

A Gain for the Nation

To illustrate the potential gain for the nation of a comprehensive, integrated approach to health reform, the Path to a High Performance U.S. Health System report published in February 2009 by the Commonwealth Fund Commission on a High Performance Health System outlined specific reforms related to provider payment, information systems, population health, and coverage that—in combination—could ensure affordable coverage for all, achieve savings, and improve population health.

The U.S. must establish a process for reaching national agreement on long-range goals and priorities for improvement in order to accomplish comprehensive, integrated health reform. This will require national leadership and a mechanism for the federal government to consult with the public as well as private health care stakeholders. The recommendations outlined here would take us a long way toward ensuring that the U.S. has a high-performing health system that simultaneously ensures better access, improved quality, and greater value. The importance of goal-setting, coordinated policies, and leadership must be considered as health reform legislation takes shape in Congress.

Health System Performance Goals for 2020
and Shorter-Range Target Indicators: Illustrative Examples


Post Comment Read or Post Comments

Symon Watson of Health Insurence Broker says:
April 16, 2010

Health Reform Betters Children’s Health Care

On February 4th 2009 the Children’s Health Insurance Reauthorization Act was signed by President Obama. It is also known as the State Children’s Health Insurance Program (SCHIP). It continued medical coverage for over five million children and added at least four million more to the medical coverage. Because of this program there are at least eleven million children insured that would otherwise not be able to afford medical coverage.

Cynthia Weinmann of APS Healthcare says:
July 13, 2009

It is encouraging to see The Commonwealth Fund recognize that the fragmentation in the US health system leads to tremendous breakdowns in quality, continuity, and coordination of care. These breakdowns are costly, create the potential for serious patient safety concerns, and raise barriers to patient-centered care.

As critical as they are, more than national leadership, national goals, and national measurement is needed. We need leadership at the level of individual patient care - an individual commitment to deliver the right person-centered care, in the right setting, and in the right amount for every person touched by the healthcare system, every time, without fail.

A recent personal experience demonstrated to me once again that too often, healthcare professionals do not "connect the dots" - using information gathered to make timely judgments about patient needs, conveying information and actions in a caring way to patients and their families, following up to evaluate results, and changing course if the results are not appropriate. Just as importantly, providing care for the person who is the patient is also too often overlooked. By this I mean, for example, clean hospital gowns and sheets, recognizing if the person cannot navigate the meal trays in any real way and needs assistance, helping with a glass of water if the person cannot lift her hand - simple, human actions to help someone who is sick. This basic level of care, of connection, of responsibility and accountability, it seems to me, has been lost in the "systemization" of healthcare. Yet I know this care is possible because I have experienced it, along with the evidence-based practice, optimal outcomes, and efficient use of resources it entails.

Without the foundation of care for one person at a time I find it hard to understand how we expect the care for many to rise to the levels we need at the state and national level.

greg vigdor of washington health foundation says:
July 8, 2009

excellent article. our healthiest state in the nation campaign in washington state agrees with the fundamental point and have offered up the following specific legislative recommendation relating to the current house reform draft in this regard, emphasizing a process to set agreed on and useful goals for an ongoing national health report card:
Legislative Recommendation: Add a section, in Section 1709 or Section 3121, stating as follows:
Congress directs the Secretary of Health and Human Services to develop a National Health Report Card that sets goals for national health reform through simple and understandable measures, and to use this tool to communicate broadly to the public on our successes and failures with respect to these goals. These goals should broadly include the aims of controlling health costs, providing access to affordable and high quality health care, and the promotion of health for the American people. The Secretary is authorized to establish an advisory committee composed of public and private experts to help develop recommendation for the National Report Card. These recommendations should be submitted to Congress by July 2010, and should consist of no more than ten broad and highly recognizable health indicators. These should be recommended for use by the public, policy makers and the media as broad gauges of the effectiveness of national health reform and, specifically, the achievement of the primary objectives of health care cost containment, increased access to care and population health improvement. Upon approval, these numbers should be published widely at least once each year, and the Secretary will make a supplemental report to Congress explaining in greater detail the implications of the findings. The measures should be population wide and reported by race/ethnicity and income. They should be certified by the Centers for Disease Control and Prevention for accuracy and reliability. The measures should include a limited, simple and understandable combination of medical care cost, access to care and social determinants of health.

Les DelPizzo of Quality Insights of Delaware says:
July 8, 2009

There are two things needed to make this proposal more organic: (1) it needs to be institutionalized, so that new administrations would have difficulty ignoring or changing this process, and (2) it needs to be somewhat "de-politicized" so that the process maintains some scientific/technical integrity.
Thus, the issue might be where this process is "housed" and who "owns" it... In my view, it needs to be maintained by something like MedPac, but with a broader mission, as outlined... To be organic to a political system, however, the report from this owning body would be required to go through the President and the President required, within some limited time, to present it to the Congress, with comment, if desired... Congress should have only "up or down" power of approval...
For maximum effect, this report should be incorporated into the President's budget proposal each year and presented to Congress as part of that process...

george lundberg of Stanford University says:
July 8, 2009

Karen and Steve,
Splendid column. The public setting of goals is so important. Your sensible statement, along with Paul O'Neill's recent published reminder about still unmet patient safety needs, are refreshing variants from all the.....usual.....costs.....politics.....lobbying......compromise.....cant do it...... tripe. Thanks. Keep up the Good work.
George D Lundberg,
President and Chair, The Lundberg Institute
Berkeley, CA