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 16 members—distinguished experts and leaders representing every sector of health care, as well as the state and federal policy arenas, the business sector, and academia—are charged with promoting a high-performing health system that provides all Americans with affordable access to excellent 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 very young and the aged, and people in poor health.
The Commission’s principal accomplishments have been to highlight the need for improvement in health system performance, identify areas where improvements can be achieved, and 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, the requirement for everyone to have coverage, the availability of premium and cost-sharing subsidies for low- and moderate-income families, and payment and delivery system reforms—were advanced by the Commission through its reports and official statements.
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, as a whole, comes up short compared with what is achieved not only in other nations but also in some areas within the U.S. Although the nation’s health spending is by far the highest in the world, we are the only high-income nation 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 and other recent legislation offer policy tools that can be used to address many of these problems. But much work remains. In the coming year, the Commission will seek to reinforce the principles and goals of a high performance health system, helping the nation to advance the unfinished agenda to control health care costs, improve value, and ensure that all Americans have access to affordable, efficient, high-quality care.
A Framework for a High Performance Health System
In its first report, Framework for a High Performance Health System for the United States (2006), the Commission outlined a vision of a uniquely American, high performance system. That report established high performance as an achievable objective for the U.S. health system and defined the key strategies necessary to reach that objective. Two years later, the report Organizing the U.S. Health Care Delivery System for High Performance highlighted the detrimental effects of the nation’s fragmented health care delivery and payment systems and offered recommendations for establishing greater coordination across providers and care settings. Among other changes, the Commission favors moving away from fee-for-service payment and toward bundled-payment methods that reward coordinated, high-value care.
Making the Case for Reform
In 2007, the Commission on a High Performance Health System released A Roadmap to Health Insurance for All: Principles for Reform, making the case for achieving universal coverage by building on the nation’s longstanding mix of private group insurance plans and public programs—a course of action intended to retain the best features of our current system while minimizing dislocation for Americans who currently have good coverage. While ensuring that everyone has health insurance is essential, the Commission believes that doing so is alone not enough to drive the kind of reform our health system needs. In its report A High Performance Health System for the United States: An Ambitious Agenda for the Next President (2007), the Commission set forth 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. The Affordable Care Act was designed with many of these same goals in mind.
Tracking Health System Performance
The Commission has issued three national and two state-level scorecards for the U.S. health system, and in March 2012 released a new scorecard for health system performance at the local level. These reports take a broad look at how the health care system is doing and where improvements are needed, as well as models of exemplary care from which others may learn. They look at such issues as: 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?
Rising to the Challenge: Results from a Scorecard on Local Health System Performance, the first-ever scorecard to focus on health system performance within the nation’s hospital referral regions, provides U.S. communities with comparative data that they can use to assess the performance of their health systems, establish priorities for improvement, and set achievement targets. The findings show clearly that when it comes to health care access and care experiences, where one lives matters. On many of the key health system indicators measured, including insurance coverage, preventive care, mortality rates, potentially avoidable hospital use, and costs, the scorecard finds significant differences between leading and lagging localities, and wide disparities among major cities. An interactive map accompanying the report allows comparison of cities and communities across the U.S.
The 2011 edition of the National Scorecard on U.S. Health System Performance finds that despite pockets of improvement, the United States as a whole failed to improve when compared with the top 10 percent of U.S. states, regions, health plans, or health care providers, or the top-performing countries. The scorecard measures the health system across 42 key indicators of health care quality, access, efficiency, equity, and healthy lives. In particular, the report notes significant erosion in access to care and affordability of care, as health care costs have risen far faster than family incomes. The bright spots in U.S. performance have been in blood pressure control, heart attack and pneumonia care in hospitals, and prevention of surgical complications—all of which have been the focus of public reporting or collaborative improvement initiatives.
The Commission’s State Scorecard on Health System Performance offers a metric for evaluating individual states on access to care, 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 the state scorecard, released in 2009 along with an interactive map showing state-by-state comparisons, identified continued wide variations in health care quality, access, costs, and outcomes.
Developing Policy Options
In its 2007 report, Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending, the Commission demonstrated how policies that are designed to improve health system performance can also reduce spending growth. In fact, the set of policies examined by the Commission would, if combined with universal health insurance coverage, lead to a decline in national health expenditures of more than $1.5 trillion over 10 years. At the same time, the nation would reap the benefits of improved access to health care, higher-quality care, and better health outcomes.
As the national health reform debate began taking shape in early 2009, the Commission unveiled an array of comprehensive insurance, payment, and system reforms that could help make affordable health coverage widely available, lead to improved health outcomes, and slow the growth of health spending by $3 trillion by the end of the next decade. A number of options presented in The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way are similar to provisions that were later part of the Affordable Care Act.
Helping to Realize the Potential of Health Reform
A central piece of the health reform legislation was the creation of the Center for Medicare and Medicaid Innovation, which is tasked with developing and implementing new models of health care financing and delivery that will improve care and reduce cost growth. The center will also monitor the impact of these models and help spread ones that are successful. In the 2010 issue brief Developing Innovative Payment Approaches: Finding the Path to High Performance, the Commission proposed a set of principles that would facilitate innovation while helping to maintain the fiscal integrity of the Medicare and Medicaid programs.
An approach to health care financing and delivery reform that has attracted much attention is the accountable care organization (ACO), a group of health care providers that, in partnership with payers, agrees to take responsibility for the quality and cost of care delivered to a defined population. In the 2011 report High Performance Accountable Care: Building on Success and Learning from Experience, the Commission provides a set of recommendations for ensuring the successful implementation and spread of the ACO model, which holds promise as an effective and efficient way to deliver care, especially to people with chronic or complex medical conditions.
A 2012 report from the Commission called on the federal government to develop a comprehensive, disciplined strategic plan to take full advantage of the new opportunities in recent health care legislation. In The Performance Improvement Imperative: Utilizing a Coordinated, Community-Based Approach to Enhance Care and Lower Costs for Chronically Ill Patients, the Commission lays out a strategy for addressing one of the greatest health system challenges: improving the coordination of health services provided to people with multiple chronic health conditions. Five percent of the U.S. population accounts for 50 percent of all health care costs, and most in this group have chronic diseases like congestive heart failure, coronary artery disease, and diabetes. The report argues that the nation should be able to achieve substantial improvements in care for these patients, while saving billions in health care costs, through coordinated, locally based efforts.
Providing Access for Vulnerable Populations
The Commission also has released a series of reports focusing on the need to ensure access to a high-performing health system for vulnerable populations, including people without health insurance, families with low incomes, and disadvantaged minorities. In Ensuring Equity: A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations, the Commission examines the challenges and offers strategies to close the health care divide. In Toward a High Performance Health System for Vulnerable Populations: Funding for Safety Net Hospitals, the Commission recommends ways to shore up safety-net hospitals so they are able to serve their communities effectively.
In addition to formulating options for improving the health system and recommendations for implementing reform legislation, the Commission on a High Performance Health System seeks to engage and inform lawmakers and staff in the executive and legislative branches, as well as key health care stakeholders, through bipartisan briefings and meetings. The Commission’s senior policy director, Rachel Nuzum, who also directs The Commonwealth Fund’s Federal and State Health Policy program, provides policymakers in both branches of government with information and technical assistance that draw upon the work of the Commission and the Fund. Staff from the Fund and the Commission are also frequently called upon by federal and state legislators to provide expert testimony and assistance.
Despite the gathering momentum for meaningful health system reform in both the private and public sectors, the work of the Commission on a High Performance Health System is far from complete. Over the coming months, the Commission will work to:
- inform implementation of the Affordable Care Act and assess its potential to move the U.S. along the path to a high performance health system
- help health care leaders and the American public understand the legislation and what it means for them
- lay the groundwork for future delivery system change and health policy action.
The Commission will also continue its efforts to assess national and state health system performance and inform health policy at all levels.