The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way

February 19, 2009 | Volume 105

Authors: Commission on a High Performance Health System
Contact: Cathy Schoen
Notes: The Lewin Group's technical documentation is available at


"This integrated approach could achieve access for all, improve population health, and provide more positive patient experiences. "

The Commission's Strategic Vision

The Commission has identified five essential strategies for comprehensive reform:

  • 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.

Together, these strategies comprise the framework for this report with recommendations for policies that would move from concept to action.

Taking the Path: Commission Recommendations

The Commission offers the following set of recommendations to move onto a path to a high performance health system. The Commission believes all the recommendations are desirable, many necessary, but none on its own sufficient to achieve high performance. Designed to move forward quickly with a sense of urgency, the comprehensive reforms include significant changes that would introduce a new dynamic and more positive path over the next decade. With cost pressures mounting and coverage eroding, the stakes are high. Starting now is crucial.

1. Affordable Coverage for All: Ensure Access and Provide a Foundation for System Reform
To build on the current mixed private and public coverage system to extend affordable health insurance to all with a strategy designed to ensure access and continuity and provide a foundation for payment and system reforms, the Commission recommends policies that:

  • Establish a health insurance exchange that offers an enhanced choice of private plans and a new public plan. This new public plan would offer comprehensive benefits with incentives for disease prevention and payment methods that reward results. It would build on Medicare's claims administrative structure and national provider networks. The exchange and new public plan would be open to all, including large employers.
  • Require individuals to have coverage and employers to offer coverage or contribute to a trust fund for insurance, sharing responsibility to pay for insurance for all.
  • Provide income-related premium assistance to make coverage affordable.
  • Expand eligibility for and improve payment under Medicaid and the Children's Health Insurance Program to improve affordability and access. Eliminate Medicare's two-year waiting period for the disabled.
  • Set a minimum benefit standard to ensure access and adequate protection from the financial burden of obtaining needed health care.
  • Reform health insurance markets to improve insurance efficiency, access, and affordability by prohibiting premium variation based on health and guaranteeing offer and renewal of coverage to all regardless of health status.

By moving from fractured to continuous insurance coverage, these reforms would lower insurance administrative costs and provide a foundation for more coherent and effective payment and system reforms. All payment reforms would apply to current public programs (i.e., Medicare and Medicaid) and to the new public plan offered through the exchange to the under-65 population. Market reforms would focus competition among insurers on improving health outcomes and adding value. Businesses, patients, and families could choose among an array of national and regional private plans and the nationwide publicly sponsored option.

2. Aligned Incentives and Effective Cost Control: Payment Reform to Enhance Value
Change the way we pay for care to reward high quality and prudent stewardship of health care resources and to encourage reorganization of care so that it is well-coordinated and responsive to patients' needs. To move away from the current fee-for-service payment system toward one that emphasizes value rather than volume, the Commission recommends policies to:

  • Strengthen and reinforce patient-centered primary care through enhanced payment of primary care services and changing the way we pay for primary care to encourage the adoption of the medical home model to ensure better access, coordination, chronic care management, and disease prevention.
  • Promote more effective, efficient, and integrated health care delivery through adoption of more bundled payment approaches to paying for care over a period of time, with rewards for quality, outcomes, and patient-centered care, as well as rewards for efficiency tied to high performance.
  • Correct price signals in health care markets to better align payments with value.

3. Accountable, Accessible, Patient-Centered, and Coordinated Care: Organize and Redesign the Delivery System to Improve Patient Experiences
Move from the current fragmented health care delivery system to one that is patient-centered, accessible, and organized so that patients and families can navigate care easily and one that holds providers accountable for high-quality, effective care across the continuum of care and over time. To move toward a delivery system in which everyone has a personal source of care that is accessible, coordinates care, and is accountable for obtaining the best health results, the Commission recommends policies that:

  • Have patients designate a personal source of care that meets standards of accessibility, quality, and coordination and can serve as a medical home.
  • Facilitate appropriate care and manage chronic conditions through integrated delivery systems that provide a continuum of care or provide funding and technical assistance for statewide and community efforts to support and connect primary care and more specialized resources in informal or virtual networks.
  • Develop provisions in which providers participating in a hospital-physician organization receiving bundled payments would be eligible for medical liability coverage on favorable terms.

4. Improved Quality and Health Outcomes: Invest in Infrastructure and Public Health Policies
Invest in infrastructure to improve the availability, quality, and usefulness of information for health care decision-making by patients, providers, and payers and encourage a culture of continuous learning. To achieve these goals the Commission recommends actions that would:

  • Accelerate adoption and use of health information technology (HIT) by establishing system standards, requiring electronic reporting of clinical information, and providing start-up funding for a national health information network so information follows the patient and is available to providers and patients.
  • Support and inform better health care decision-making by establishing a Center for Comparative Effectiveness and Health Care Decision-Making, encouraging shared decision-making based on evidence, and using recommendations to develop value-based benefit designs that preserve choice but encourage appropriate care.
  • Provide more transparent information to guide and drive innovation by requiring all-population, all-payer quality, patient experiences, and cost data with benchmarks of top performance.

Invest in improving population health with the goal of lowering the rates of preventable illness and improving health outcomes for chronic conditions with efforts to:

  • Target public health initiatives on prevention of illness, including expansion of immunizations that are demonstrated as effective and public health actions and tax incentives and other initiatives to reduce obesity and decrease tobacco use and promote healthy lifestyles.
  • Design health insurance benefits to encourage and support preventive care and essential care for chronic conditions, with positive incentives for patients to engage in health promotion and keep existing chronic conditions under control.
  • Intensify the focus on preventing and managing chronic conditions, including incentives for more coordinated care and setting goals to improve outcomes for chronic conditions that account for the bulk of health care needs and spending.

5. Accountable Leadership and Collaboration: Coordinated Efforts to Improve the Health System
Leadership, new national policies, and collaboration among the public and private sectors will be necessary to set and achieve national goals for high performance. To provide accountable leadership and foster collaboration, the nation will need to establish mechanisms to set and achieve national goals, enable public programs to serve as prudent purchasers of care, and ensure coordination of practices and policies that cut across public programs and private sector activities. In addition to insurance reforms, we need national leadership to:

  • Set performance targets and provide incentives and technical assistance to meet them.
  • Authorize public programs, including Medicare, to be more active purchasers of high-value health care for their beneficiaries, rather than passive payers. This would include implementing and facilitating the adoption and rapid spread of innovative payment policies to elicit a more effective, efficient, and responsive delivery system.
  • Establish a national insurance exchange that would operate at national, state, and regional levels to allow participation of regional private health plans and integrated delivery systems
  • Establish a Center for Comparative Effectiveness and Health Care Decision-Making.
  • Set national standards to accelerate adoption and use of health information technology and a national health information network.