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Aiming High: Targets for the U.S. Health System

Foundations historically have responded to voids in public policy by supporting commissions to investigate the state of affairs and chart a course for change. In the area of health care, the Flexner Commission, sponsored by the Carnegie Foundation for the Advancement of Teaching, transformed the quality of medical education with its 1910 report. The Commission on Hospital Care, supported by The Commonwealth Fund, W. K. Kellogg Foundation, and National Foundation on Infantile Paralysis in 1942, was pivotal in the enactment of the 1946 Hill-Burton Act, which helped build and modernize the nation's hospitals. And there have been others.

The Commonwealth Fund feels the time is again ripe for foundation leadership and thus has established a Commission on a High Performance Health System. The Commission has just begun its work yet it has already identified 10 priorities for deliberation and, ultimately, for a high performance health system, which would be organized around these core values:

  1. Long, healthy, and productive lives

    At the most basic level, what Americans want from their health care system is "life, liberty, and the pursuit of happiness." They want to benefit from the best of modern medicine, free from worry about medical bills and assured that they and their loved ones will have the opportunity to be healthy and productive. The reality is starkly different, and the many ways in which our health outcomes lag behind those in other industrialized countries cannot be attributed solely to differences external to the health system, such as our higher poverty rate.

    The flaws in the U.S. health system affect Americans' economic productivity. A 2005 report by the National Committee for Quality Assurance found that improving the performance of all health plans to the level of the best-performing plans would save between $2.8 billion and $4.2 billion in medical costs, avoid 83 million sick days, and increase productivity by $13.5 billion.
  2. The right care

    Poorer health outcomes can be attributed in part to the failure of our health system to ensure that Americans get the right care. A RAND Corporation study documented that recommended care is delivered only 55 percent of the time. While those without health insurance are much less likely to receive high-quality care, quality of care is uneven even for those with coverage. One analysis of Medicare medical records found wide variations across states on 22 quality indicators. More needs to be done to understand why states like Maine and Minnesota consistently rank in the top tier while states like California, Florida, and Texas consistently rank near the bottom.
  3. Coordinated care over time

    Very few things are more debilitating or discouraging to seriously ill patients and their families than navigating the complex U.S. health care system. Fund surveys have found that Americans are more likely than patients in other countries to report problems with coordination of care, including medical records that are not available when they show up for appointments, doctors who order duplicate tests, and other shortcomings.

    The Fund is supporting an evaluation of a project that uses advanced practice nurses to follow elderly congestive heart failure patients after hospital discharge. This simple intervention reduces the percentage of patients who are rehospitalized and cuts the total cost of care by over 35 percent. The Medicare program has selected this promising model as one of eight to be included in a pilot project on improving chronic care.
  4. Safe care

    Five years after the landmark Institute of Medicine report To Err Is Human, supported in part by the Fund, the U.S. health system still gets a C+ on patient safety. Some promising actions are being taken, however. The 100,000 Lives Campaign, spearheaded by the Institute for Healthcare Improvement, has engaged more than 2,900 hospitals in reducing preventable adverse events—such as acquiring ventilator-associated pneumonia—that can cost lives. The Joint Commission on Accreditation of Healthcare Organizations requires that hospitals notify patients of preventable adverse events, and some state health agencies require reporting of medical errors. Insurers could reinforce these efforts by declining to pay for hospitalizations in which patients experience one of 27 well-defined "never events"—serious, largely preventable adverse events that should never happen in American hospitals, according to the National Quality Forum.
  5. Patient-Centered Care

    Some leading organizations have vastly improved the services they provide to patients by mapping out the patient's journey through the health system and figuring out ways to make it smoother and more satisfying. "Patient-centered care" can foster better quality as well as simple efficiency. For example, about half of patients report shortcomings in communicating with their physicians: they leave the doctor's office with unanswered questions, do not perceive that the physician always listens carefully, or do not understand the explanations the doctor offers. In many cases, the result is failure to adhere to recommended treatments and an increased risk of emergency care.

    Increasingly, patients want to be active partners in their care. As decision-makers, they want information about their conditions and access to their records. Such partnerships are essential if patients are to manage chronic conditions effectively and adopt healthier lifestyles.
  6. Efficient, high-value care

    The U.S spends far more of its economic resources on health care than other countries. Yet higher spending doesn't mean that we receive more or better care; we simply pay more. Other major industrialized countries pay less than half what we pay for prescription drugs. They also invest more in primary care and less in specialist care, perhaps gaining more value per dollar spent.

    Particularly troubling are new studies finding wide variations in the cost and quality of U.S. health care. One Fund-supported study found that the quality of care varies widely from hospital to hospital and city to city. Others studies show no clear relationship between health outcomes and costs, for example, the cost of hospital care and hospital mortality rates.

    In many ways, we get what we pay for. Our fee-for-service system rewards the provision of specialized services, not good outcomes, and gives hospitals no financial incentive to reduce complications or prevent rehospitalizations by making sure patients understand how to take their medications and manage their conditions at home. If we want change, we need to reward the outcomes we desire.
  7. Universal participation

    Despite spending more on health care than any other nation, the U.S. is the only industrialized nation without universal health coverage. The number of uninsured Americans has increased steadily over the last five years, from 40 million in 2000 to 46 million in 2004. Data from 2003 show that another 16 million adults were underinsured, meaning their insurance did not protect them adequately against catastrophic expenses.

    In the absence of federal leadership, some states have responded by adopting programs to expand health insurance coverage. The state of Maine, for example, recently enacted Dirigo Health Care, which lets small businesses buy coverage, with workers paying their share of premiums on a sliding-scale basis. The Fund gave support for technical assistance to design and launch this program, which bears careful monitoring as a possible model for other states and the nation.
  8. Affordable care

    The high cost of care and inadequate coverage undermine the financial security of millions of Americans. Two of five adults—an estimated 77 million people age 19 or older—struggle with medical bills, have recent or accrued medical debt, or both. Even those who are insured are not immune: three-fifths of working-age people who reported problems were insured at the time their medical bill or debt problem occurred.

    The trend toward higher deductibles in employer plans may be undercutting one of the major purposes of health coverage: protecting against financial catastrophe. High out-of-pocket costs are particularly difficult for lower-income families. Twenty-nine percent of adults with incomes below $20,000 spend over 5 percent of their incomes on out-of-pocket health care costs, not including premiums, compared with 2 percent of those with incomes above $60,000.

    Affordability is an issue for many employers as well. The proportion of firms offering health benefits has declined from 69 percent in 2000 to 60 percent in 2005. And if health care costs continue on their current course, a greater and greater share of the federal budget will need to be devoted to Medicare and Medicaid, which provide insurance coverage to our nation's oldest, sickest, and poorest individuals.
  9. Equitable care

    For too long, we have tolerated wide disparities in the opportunity to live a healthy life. The disparities exist along many dimensions, but perhaps most striking are differences associated with insurance coverage, income, race or ethnicity, health status, and age. In a country that prides itself on equal justice for all, it is difficult to find any dimension of the health system that performs equally for all Americans. Low-income workers, for example, are less likely to have sick leave and paid time off to see a physician. And minority patients are more likely to have chronic conditions such as diabetes or hypertension, and less likely to have those conditions well controlled.
  10. Knowledge and capacity to improve performance

    We can do better. We have the wealth, the health care institutions, the dedicated professionals, the technological progress, the medical research, and the ingenuity required to make the U.S. health care system truly the best in the world.

    To mobilize those resources more effectively, we need much better information on health system performance—nationally, regionally, and at the level of the individual health system, hospital, or medical group. We need a transparent system, with information accessible to everyone—patients, their families, health care professionals, and those who pay for care, including insurers, employers, and government agencies. We need a modern information system that makes it easy for health professionals to give the right care in the right way every time.


This is asking a lot, but transformation is indeed possible. A recent Fund survey of health care leaders found that respondents were surprisingly unified in their opinions of what strategies are most promising, such as letting small businesses and individuals buy coverage through the Federal Employees Health Benefit Program; giving incentives to employers to expand coverage; rewarding more efficient and high-quality providers; and improving disease management and primary care case management.

The Commonwealth Fund Commission on a High Performance Health System will systematically examine these and other options available to a nation with our exceptional resources and capacity. It is our hope that the Commission's work will be pivotal in moving the nation toward a high performance health system that offers better access, improved quality, and greater efficiency to all Americans.

As always, I'd like to hear from you. Send your feedback to [email protected].





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January 2006


Written with the assistance of Christine Haran, web editor.