Commission Goals
In establishing the Commission on a High Performance Health System in 2005, The Commonwealth Fund's Board of Directors recognized the need for national leadership to revamp, revitalize, and retool the U.S. health care system. The Commission's 17 members, a distinguished group of experts and leaders representing every sector of health care, as well as the state and federal policy arena, the business sector, professional societies, and academia, are charged with promoting a high-performing health system that provides all Americans with affordable access to high-quality, safe care while maximizing efficiency in its delivery and administration. Of particular concern to the Commission are the most vulnerable groups in society, including low-income families, the uninsured, racial and ethnic minorities, the young and the aged, and people in poor health.
The Commission's principal accomplishments have been to highlight specific areas where health system performance falls short of what is achievable, and to recommend practical, evidence-informed strategies for transforming the system. Many of the major ideas in the Affordable Care Act—among them, new insurance market regulations, requiring everybody to have coverage, providing premium and cost-sharing subsidies to low- and moderate-income families, and payment and delivery system reforms—were advanced by the Commission through the reports and statements it has issued over the past half-decade.
The Commission is chaired by David Blumenthal, M.D., Samuel O. Thier Professor of Medicine and Professor of Health Care Policy at Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School. Fund staff members Stuart Guterman, Cathy Schoen, and Rachel Nuzum serve as executive director, research director, and senior policy director, respectively.
The Issues
The United States provides some of the best medical care in the world, yet a growing body of evidence indicates that our health care system comes up short in comparisons with other industrialized nations. Although health spending in the U.S. is significantly higher than in other advanced countries, we are the only such country that fails to guarantee universal health insurance, and millions of our citizens lack affordable access to primary and acute care. Moreover, the care that is provided is highly variable in quality and often delivered in a poorly coordinated fashion—driving up costs and putting patients at risk.
The Affordable Care Act seeks to address these problems. Over the next several years, the Commission will dedicate itself to monitoring the law's implementation and impact, and to recommending modifications that would make the reforms more effective.
Recent Projects
Tracking Health System Performance. In its first report, Framework for a High Performance Health System for the United States, published in 2006, the Commission traced the critical sources of health system failures and outlined a vision of a uniquely American, high performance system. Since that initial report, the Commission has issued two national and two state-level scorecards for the U.S. health system. These reports take a broad look at how well the health care system is doing, where improvements are needed, and what examples of good care exist that could serve as models for the rest of the country. They look at specific issues: Do people have access to the health care they need? Are they getting the highest-quality care? Are we spending money and using health care resources efficiently?
The 2008 edition of Why Not the Best? Results from the National Scorecard on U.S. Health System Performance finds that in nearly every area of performance measured, the health system performed worse than it did in 2006, scoring just 65 out of 100 across 37 core indicators—where 100 represents not necessarily what is ideal, but what has actually been achieved by the best performers. Despite some good news in the report—for example, performance on a key measure of patient safety, hospital-standardized mortality ratios, saw significant improvement—the U.S. health system continues to operate far below the performance of leading nations, states, delivery systems, and hospitals.
The State Scorecard, first published in 2007, offers a metric for evaluating individual states' health care systems on access, prevention and treatment quality, avoidable hospital use and costs, health outcomes, and equity—with the goal of spurring policymakers and private stakeholders to undertake efforts to improve their performance to benchmark levels and beyond. The second edition of Aiming Higher: Results from a State Scorecard on Health System Performance reports that the cost and quality of health care, as well as access to care and health outcomes, continue to vary widely among states. An interactive map that accompanies the report provides state-by-state comparisons, as well as estimates of lives and dollars saved if performance were brought up to benchmark levels.
Making the Case for Reform. The Commission believes that while ensuring that all Americans have health insurance is essential, doing so is alone not enough to drive the kind of reform our health system needs. In the 2007 report, A High Performance Health System for the United States: An Ambitious Agenda for the Next President, the Commission discussed concrete goals—and the strategies for achieving them—that should be on the national health care agenda, including: guaranteeing affordable health insurance for all; containing growth in health care costs and reforming provider payment; fostering greater organization and integration of care delivery; speeding adoption of health IT, evidence-based medicine, and other infrastructure; and setting and meeting national goals through strong national leadership.
Later in 2007, in A Roadmap to Health Insurance for All: Principles for Reform, the Commission makes the case for achieving universal coverage by building on the current mix of private group plans and public programs—a course of action that would retain the best features of our current system while minimizing dislocation for Americans who currently have good insurance coverage.
The Commission also has issued a number of policy reports with specific recommendations for achieving higher system performance. The 2008 report, Organizing the U.S. Health Care Delivery System for High Performance, points out the detrimental effects of fragmentation in the current system and offers recommendations for establishing greater coordination across health care providers and care settings. For example, the report recommends moving away from fee-for-service payments and toward bundled payment systems that reward coordinated, high-value care. As reported in a Commission data brief, eight of 10 U.S. adults believe the health system needs fundamental change or complete rebuilding, and most want their health care to be more patient-centered and integrated than it currently is.
Developing Policy Options. Certainly one of the most important reports published by the Commission is Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending, which lays out in detail federal options for both short- and long-term savings within the health care system. The Lewin Group modeled the likely effects of each option and estimated the five- and 10-year cumulative impact on total national health spending, as well as the effects across federal and state budgets, employers, and households. The analysis determines that if implemented along with universal health coverage, selected policy options could save $1.5 trillion in national health expenditures over 10 years, while also improving the value of care in terms of access, quality, and health care outcomes.
As the national health reform debate began taking shape in February 2009, the Commission released another groundbreaking report, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way. The comprehensive insurance, payment, and system reforms described in the paper would guarantee affordable health insurance coverage, improve health outcomes, and slow the growth of health spending by $3 trillion by the end of the next decade, according to projections. Many of the policy options presented are similar to those included in the new health reform legislation.
Informing Policymakers. In addition to formulating policy improvement options and recommendations for health reform implementation, the Commission on a High Performance Health System works to engage and inform policymakers in the executive and legislative branches and key health care stakeholders. The Commission sponsors bipartisan briefings and meetings for members of Congress and their staff. Senior policy director Rachel Nuzum also provides legislators and government officials with testimony and technical assistance as requested.
The Washington-based Alliance for Health Reform receives support from the Fund to conduct the briefings and roundtable discussions, as well as an annual bipartisan congressional retreat and congressional staff retreat, which give members of Congress and their senior staff a unique opportunity for off-the-record discussion of pressing health policy issues.
Future Directions
Even with the passage of comprehensive health care reform, the work of the Commission on a High Performance Health System is far from complete. Over the coming months and years the Commission will closely monitor implementation of the reform package, report on areas of concern, and issue recommendations for policy modifications as necessary. Additional, complementary health system reforms also will be studied. Finally, the Commission will continue its efforts to assess national and state health system performance as well as inform health policy at all levels.