The Commonwealth Fund marshaled its resources this year to produce timely and rigorous work that helped lay the groundwork for the historic Affordable Care Act, signed by President Obama in March 2010.
Anna Harkness founded The Commonwealth Fund in 1918 with the mandate to "do something for the welfare of mankind." To that end, The Commonwealth Fund and its Commission on a High Performance Health System have become leading voices for reforming the U.S. health care system—to achieve insurance coverage for all, at reasonable cost, and to ensure that services are coordinated, patient-centered, and efficiently delivered. Long before health reform became a staple of national headlines, the Fund was working to provide much-needed data on the impact of spiraling health care costs on middle-class families, businesses, and government and proposing options for "bending the cost curve." We also provided information on how the U.S. health system compares internationally—further evidence to build a compelling case for reform.
The Commission's 2008 National Scorecard on U.S. Health System Performance—the second one it has issued—showed that the nation was losing ground in health care. In nearly every category measured, the new scorecard found that the health system performed worse than it did in 2006—largely because of worsening access to care. Similarly, Fund surveys comparing the U.S. to other industrialized nations repeatedly found that the U.S. falls far short of its peers in access, safety, and efficiency. And a highly publicized Fund-supported study released in 2008 found that the U.S. had dropped to last place, among 19 countries, on "mortality amenable to health care"—a measure of how well a health system prevents potentially avoidable deaths by ensuring that people receive timely, appropriate care for treatable conditions.
Commonwealth Fund professional staff, Commission members, and grantees also spent this critical period developing strategies to extend health insurance to all, improve care delivery, and reduce health care costs for government, employers, and individuals—approaches that ultimately helped shape the health reform legislation. As a result, we were in an ideal position to evaluate the reform proposals of the 2008 presidential candidates—and outline reform options for President Obama before he took office—drawing on such reports as An Ambitious Agenda for the Next President and The 2008 Presidential Candidates' Health Reform Proposals: Choices for America.
Working toward solutions, the Fund also launched two multiyear quality improvement initiatives—one to develop patient-centered medical homes that redesign care to ensure 24/7 access to high-quality, coordinated primary care, and one to reduce avoidable hospital readmissions—that have already helped turn these issues into national delivery system change movements. The Safety Net Medical Home Initiative aims to develop a replicable and sustainable implementation model for medical home transformation for health centers serving low-income populations. The State Action on Avoidable Rehospitalizations (STAAR) initiative, meanwhile, is a multipronged effort administered by the Institute for Healthcare Improvement to help hospitals improve their processes for transitioning discharged patients to other care settings. We also created WhyNottheBest.org, a Web site that enables users to compare the performance of U.S. hospitals and other health care providers, and offers case studies and profiles of high-performing health care providers and best practices.
The following essays, published on the Commonwealth Fund's Web site over a one-year period, each addressed one of the five strategies for a high performance health system laid out in the Commission's report, The Path to High Performance Health System: A 20/20 Vision and the Policies to Pave the Way, released in February 2009. Those strategies for comprehensive reform are:
- Affordable coverage for all.
- Align incentives with value and effective cost control.
- Accountable, accessible, patient-centered, and coordinated care.
- Aim high to improve quality, health outcomes, and efficiency.
- Accountable leadership and collaboration to set and achieve national goals.
The essay, "Insurance in Name Only," discussed the need to improve coverage for the 25 million Americans that Commonwealth Fund research has identified as being underinsured—meaning they have health coverage but still have medical expenses they cannot afford.
"Ensuring Accountability" reviewed an approach to realigning incentives for hospitals. Global fees, which cover a bundle of services for hospitalization and 30-day post-hospital care, can improve care, reduce complications, and generate savings. Another look at improving value, "Bending the Health Care Cost Curve: Lessons from the Past," reviewed the history of failed voluntary industry efforts to contain health care costs, and showed why policymakers need to set health reform expenditure targets.
Other essays focused on the need to organize the delivery system so that providers can better offer patient-centered, coordinated care. "Delivering Change Through Health System Organization" discussed the six attributes of an ideal health care delivery system that have been identified by the Fund's Commission and offered payment reform and other policy recommendations that would help the nation achieve it. "Can Patient-Centered Medical Homes Transform Health Care Delivery?" discussed how the medical home model can strengthen primary care. "Cooperative Health Care: The Way Forward?," a timely response to a proposal floated in the Senate at a crucial moment in the health reform debate, highlighted the challenges cooperatives would face in the health care market and the need for a national authority that would provide support and set payment rates. Accompanying that essay were case studies of the two major health care cooperatives in the U.S.: Group Health Cooperative of Puget Sound, in Seattle, and Health Partners, in Minnesota.
Evidence of poor health system performance, drawn from Fund-supported research, that underscored the need for reform was examined in "Headed in the Wrong Direction: The 2008 National Scorecard on U.S. Health System Performance" and "Reducing Preventable Deaths Through Improved Health System Delivery Performance." "Health Information Technology: Key Lever in Health System Transformation" encouraged national policymakers to invest in health IT, as well as create standards and financial incentives to ensure providers will adopt and use health IT effectively.
"The Presidential Candidates' Health Reform Plans: Important Choices for the Nation," and "Health Reform in the New Era: Options for the Obama Administration" analyzed the health reform options before the country, while "Compassion and Challenging Changes in Health Care" explained how reform would benefit patients and families, as well as all stakeholders. Together, these essays provide a picture of the major health care issues of the year and the many ways that Fund research and analysis were used to support the nation's drive toward comprehensive health reform.
For more than 90 years, The Commonwealth Fund's role in health care has been to help establish a base of scientific evidence and work toward social progress by mobilizing talented people to transform health care organizations, collaborating with organizations that share its concerns, and practicing strategic communications to reach those in a position to effect change, particularly for society's most vulnerable. We look forward to continuing our efforts to improve the health care system and the health and lives of all Americans.
K. Davis, Building a Foundation for Health Reform, The Commonwealth Fund, June 2010.