Patients say it's time for change in the health system
Patients surveyed by Harris Interactive for the Commonwealth Fund report experiences of wasteful, inefficient, or unsafe health care. Half of middle-income and lower-income families reported serious problems paying for care and insurance coverage, and three-quarters of all adults said the U.S. health care system needs either fundamental change or complete rebuilding.
The Commonwealth Fund's Commission on a High Performance Health System, which is making recommendations for an improved health care system in the United States, paid for the poll in hopes that its responses would provide insight for policy actions that are grounded in the daily realities faced by patients and their families.
Overall, commission officials said, there is strong public support for efforts to improve care coordination and access to information. There is a shared belief that expanded use of information technology, practitioner teams, and improved delivery of preventive care could improve the quality of care.
Substantial majorities of those surveyed believe it is important to have one place or doctor responsible for care and coordination and to have medical records easily accessible by patients and all their physicians. However, recent studies have shown that adults in the United States generally have short-term relationships with their physicians, often lack a regular source of ongoing care, and rarely have easy access to their own medical records. Only 37% have had the same physician for the past five years or more, and only 51% reported having access to their own records.
A majority of adults believe it is important to have access to information about the quality and cost of care, and most believe that quality and efficiency should influence the amount of payments made to physicians and hospitals. But the reality patients encounter is quite different. In a survey of individuals with health insurance, only 15% reported they had access to information on quality and cost of care. And health insurance plans themselves often lack information on quality or outcomes of care over time, and are therefore unable to develop networks or incentives to reward and support clinicians who provide higher-quality, more efficient care.
While most adults surveyed view efforts to facilitate information exchange and practitioner teams as effective strategies to improve quality of care, the current environment is quite different. A 2003 survey of physicians found that only 27% used electronic medical records routinely or occasionally, and only 54% sent patients reminders about preventive care. One of three physicians practices in a solo office and about 25% are in groups of two to four physicians.
Many worry about cost, access
Affordability of care and insurance is a growing concern. In addition to concerns about costs, a high proportion of adults have serious problems getting timely care and reported spending time on paperwork and having disputes related to medical bills and insurance.
Reflecting their own negative experiences as well as worries about the future, fully 75% of all adults believe the U.S. health care system needs to be fundamentally changed or rebuilt completely. The commission said that negative view prevails across groups by income, insurance, and political affiliation.
Some 30% of adults believe the system needs to be completely rebuilt, while another 46% think the system requires fundamental changes. Only 20% of adults think the health care system works relatively well, with only minor changes needed. System views are reported to be remarkably similar across income groups and regions of the country.
More Republicans than Democrats (35% to 11%) see a need for only minor changes, but very large majorities of both parties call for fundamental changes or complete rebuilding. Strong negative views of the system were higher among those who reported having negative quality and care experiences.
The survey asked respondents to rate the importance of seven possible policy actions for the president and Congress — ensure that Medicare remains financially sound in the long term; control the rising cost of medical care; ensure that all Americans have adequate, reliable health insurance; lower prescription drug costs; improve the quality of nursing homes and long-term care; reduce insurance complexity; and reform the medical malpractice system.
Top four priorities
The top four priorities identified were ensuring that all Americans have adequate and reliable health insurance, controlling the rising costs of medical care, lowering prescription drug costs, and ensuring that Medicare remains financially sound in the long term. Commission researchers said the rank order was remarkably similar across income groups and regions of the country, but varied notably by political affiliation.
"These public views underscore the values and call for change underpinning the framework statement issued by the Commonwealth Fund Commission on a High Performance Health System," the survey report said. "The commission concluded that while the United States delivers some of the best medical care in the world, it falls far short of providing high-quality, safe, well-coordinated, and efficient care accessible to all Americans .… The United States is on the wrong track. Health care costs are escalating, and the numbers who are uninsured or underinsured are growing even greater. Patients and families want transformative change. Listening to the voices of patients about their care experiences provides a prescription for what is most ailing in our current system. Patients want a genuine system of health care, one where care is coordinated, no one falls through the cracks, and every one is secure in the knowledge that the best of American medicine will be there for them. It is a clarion call that should not go unheard."
In its framework report, the first of many commission reports expected to be released over the next few years, each increasing in specificity, commission members say the United States has some of the best-equipped hospitals and best-trained physicians in the world. "With much dedication to helping patients, they often provide extraordinary care. Nevertheless, the evidence clearly shows that, overall, the performance of the U.S. health care system falls far below the level it can and should achieve. On many dimensions of performance, from timely access to needed services to the deployment of health information technology, we lag behind other industrialized nations. Within our own borders, there are wide disparities from region to region and from state to state."
Despite spending more money on health care than any other country, the U.S. allocates resources wastefully and inefficiently, the commission said, failing to provide universal access to care and failing to achieve value commensurate with the money spent. Many patients receive treatments and procedures known to be ineffective, while other effective treatments are vastly underused. Tens of thousands die annually from preventable errors. Nearly half of all adults worry they will not be able to pay their medical bills if they become seriously ill, will not get high-quality care, or will experience a medical error.
Goals of a high-performing system
To get discussion on its proposals started, the Commission on a High Performance Health System said the overarching mission of such a system is to help everyone, to the extent possible, to lead long, healthy, and productive lives. To fulfill that mission, such a system must:
- commit to a clear national strategy for achieving the mission and establish a process to implement and refine that strategy;
- deliver care through models that emphasize coordination and integration;
- establish and track metrics for health outcomes, quality of care, access to care, population-based disparities, and efficiency.
"At present, no organization or body, except Congress, can commit to a national strategy," the commission said. "Options could range from relatively modest steps, such as a reorganized committee jurisdiction structure, to more far-reaching steps, such as the devolution of substantial congressional authority to a Federal Reserve-like structure for health care, which would set rules for public and private stakeholders."
A high performance health system, according to the commission, is designed to achieve four core goals: 1) high-quality, safe care; 2) access to care for all people; 3) efficient, high-value care; and 4) system capacity to improve.
While it plans to become much more specific in future reports in terms of recommendations for change, the commission has said it believes a mix of private and public financing, organization, and delivery will continue, at least for the foreseeable future. A high-performance health system for the United States will likely combine market forces and public policy to achieve its goals, the report said. America's challenge is to find a way to benefit from what markets can provide while pursuing alternative strategies to achieve what markets cannot.
Targeting improvement
As its next step, the commission is working on national and state scorecards to measure U.S. performance against specific benchmarks. It said those documents will be instrumental in setting specific targets for improvement.
The next step will be to envision how each stakeholder in the system is to be accountable to others, and how that accountability can be brought about. For example, the commission said, health plans should be accountable for ensuring that benefit packages include the right care; providers should be accountable to patients and to purchasers for providing the right care; employer purchasers should be accountable for providing employees with the tools to make wise choices among plans, providers, and treatments; and patients should be accountable for actively managing their health and complying with effective treatments.
Initial steps that can and should be taken, the commission said, include:
1. Expand health insurance coverage. The commission views expansion of insurance coverage as a necessary, but not sufficient, step toward universal participation in the health system.
2. Implement major quality and safety improvements. This could include promoting use of evidence-based medicine, promoting effective chronic care management, reengineering delivery within and among provider organizations, and ensuring care coordination across sites of care, especially when transitioning from the hospital to other settings.
3. Work toward a more organized delivery system that emphasizes primary and preventive care that is patient-centered. While strategies for improving quality and safety focus on creating better systems within and among health care delivery organizations, the commission said patient-centered practices should also be emphasized. And although specialty care is essential, there is increasing evidence that a high performance health system needs to focus on primary care. The commission said the key levers for promoting change are benefits design, work force training, and payment policy.
4. Increase transparency and reporting on quality and costs. Public reporting of information on the performance of health plans and providers can spur improvements in quality and efficiency, primarily by helping consumers make more informed decisions and by stimulating plans and providers to be more accountable for their results.
5. Reward performance for quality and efficiency. The commission said the health care payment system should be restructured so providers are reimbursed based on the quality of care they provide. Purchasers, both public and private, can improve quality and efficiency by building performance standards into health plan contracts and developing pay-for-performance programs that reward quality and efficiency in providing acute and chronic episodes of care.
6. Expand use of interoperable information technology. Computerized order entry systems and electronic health records developed at the organizational level can help to reduce costs and improve safety and efficacy. But for the health system to maximize benefits from the individual systems, innovation must focus on linking all pieces into an interoperable network.
7. Encourage collaboration among stakeholders. The commission said it is necessary to create a culture of high performance in which all parties share a vision of bringing high-quality health care to every person. It is particularly critical for the public and private sectors to work together.
"The commission will explore alternative models and organizational structures for setting and updating our national strategy and for measuring and tracking our performance," the report concluded. "Ultimately, the commission seeks to define the specific policies and practices that can help the nation attain this vision, and it plans to develop and disseminate recommendations to the nation. The commission believes that the nation can and must do better, and it is committed to action."
Flexibility ahead?
Meanwhile, three current or former members of the White House Council of Economic Advisors discussed health care costs at an American Risk and Insurance Association forum and created an impression that the continuing national debate over health care entitlement programs could end up being more flexible than in the past.
"We spend more than twice as much of our gross domestic product on health care as our comparable trading partners in the Organization for Economic Cooperation and Development and it doesn't seem as though our health outcomes are twice as good," said recent economic advisors appointee Katherine Blacker. She also noted a "dramatic variation" in how much is spent per Medicare beneficiary across the country and said, "The areas where we are spending more money per Medicare beneficiary are less likely to get what is fairly universally acknowledged to be higher-quality care."
Brookings Institution researcher Peter Orszag, a member of the council during the Clinton administration, said the disparity in Medicare spending suggests it is possible to constrain health care cost growth in ways that don't materially adversely affect health outcomes. He also called for more efforts such as those in West Virginia to create a "compact of personal responsibility."
"Basically, you need to take steps to take care of yourself and actually show up for medical appointments and vaccinations and what have you, and in exchange we'll provide health care," he said. "In the absence of the personal responsibility component, we could be wasting a lot of money."
Douglas Holtz-Eakin, an earlier Bush administration appointee to the council, said the United States must decide "the degree to which we want to continue to have pay-as-you-go social insurance-style systems, vs. systems that look more like self-insurance."
Making change
Commonwealth Fund Commis-sion on a High Performance Health System executive director Stephen Schoenbaum tells State Health Watch he hopes to be able to accomplish change even within the current political environment.
"The commission hopes a lot will be accomplished at the national level and also in the private sector," he says. "We're not considering that in two years this administration will turn over, but there's also enough involved in what we're doing that this is a good time to start thinking about 2008."
Mr. Schoenbaum acknowledges that as the first document the commission has issued, the framework "is pretty general in setting out the problem and stressing the need to redesign the health care system. I expect a significant amount of activity over the next couple of years to be much more specific."
Progress unlikely
Medical College of Virginia department of health administration associate professor Robert Hurley tells State Health Watch that what the Commonwealth Fund's commission has produced so far seems to be "more exhortation for action" rather than concrete, actionable proposals. And he's pessimistic about the political will to address the issues.
"I think the prospect of substantial Medicaid or health reform in general is unlikely in the next two years," he says. "Even if the fall 2006 elections lead to a shift in control, Democrats are likely to tackle less controversial issues initially as they try to solidify their position. I also think that if the economy softens, as it seems to be on the edge of doing, then we can probably forget about anything particularly ambitious. I'm sorry to sound so skeptical but the war, the deficit, and the ideological divide each seems a stopper in its own right, and rolled together they cast doubt on any constructive reform in the near term."
The commission's reports are available at www.cmwf.org. Contact Mr. Schoenbaum at (212) 606-3800. Contact Mr. Hurley at (804) 828-1891 or e-mail [email protected].
Patients surveyed by Harris Interactive for the Commonwealth Fund report experiences of wasteful, inefficient, or unsafe health care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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