Commission on a High Performance Health System

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The Commonwealth Fund Commission on a High Performance Health System, launched in July 2005, "seeks to move the U.S. toward a health care system that achieves better access, improved quality, and greater efficiency, particularly for those who are most vulnerable due to income, race/ethnicity, health, or age. The 19-member Commission will identify public and private policies and practices that change the delivery and financing of health care and improve system performance."(#1)

Purpose of health policy or idea

Improving performance of the U.S. health care system

"Despite spending more than any other country, the U.S. health care system is marked by significant shortcomings in efficiency, quality, access, safety, and affordability. The consequences are serious: widespread disparities in health based on insurance status, income, and race; patients not receiving recommended care; and thousands of Americans dying yearly from lapses in safety." (#2) 

Faced with these challenges, the Commonwealth Fund established the Commission on a High Performance Health System in July 2005. "Members of the Commission draw from all parts of the health care system-from health care delivery to health insurance-as well as the state and federal policy arena, the business sector, professional societies, and academia. The Fund's Board of Directors established the Commission recognizing the need for leadership in advancing promising strategies for health system improvement." (#3) 

Tasks of the Commission on a High Performance Health System

The Commission is charged with:

• Defining the characteristics of a high-performance health system.
• Identifying policies needed to achieve such a system.
• Setting realistic targets.
• Recommending concrete steps to achieve five-, 10-, and 15-year goals.
• Issuing an annual 'scorecard' documenting progress.
• Issuing an annual set of issue briefs on key policy topics related to achieving a high performance health system. (#1) 

The Commission's first task was "to outline a framework that organizes the myriad public and private financing and delivery mechanisms in the U.S. into a more cohesive system and identify the core goals and priorities of a high performance health system." (#2). In a report issued August 2006, "Framework for a High Performance Health System,"the Commission proposed a list of examples of initial steps that can and should be taken by the nation "to overcome system failures, improve accountability and transparency, and reward quality and efficiency." (#3) 

The second effort of the Commission was the development of an annual health system Scorecard, which will track performance along multiple dimensions of care. Results from the "National Scorecard on U.S. Health System Performance" were released in September 2006. In the Executive Summary of the report, it was noted that "the Scorecard is the first-ever comprehensive means of measuring and monitoring health care outcomes, quality, access, efficiency, and equity in one report. Its findings show that America's health care system falls far short of what is attainable, especially in consideration of the resources the nation invests." (#6) 

According to Commission Chairman James J. Mongan, M.D. and the Fund's Executive Vice President Stephen C. Schoenbaum, M.D., "the Scorecard findings highlighted for us the problems of fragmentation of our health system and the need for cross-cutting policies and practices to improve the system and its performance." The Scorecard will inform the Commission's future work and will be updated on an annual basis (#6).

Main points

Main objectives

In the Commision report, "Framework for a High Performance Health System in the United States," the authors demonstrate "how the U.S. health care system fails to perform sufficiently well across 10 dimensions of high performance: providing for long, healthy, and productive lives; getting the right care; safe care; coordinated care; excellent care and service from the patient's perspective; universal participation; equity; efficiency; affordability; and the capacity to improve. They describe the unique features of the U.S. health care system and illustrate how it constructs roadblocks on the path toward high performance. Finally, they explore potential levers that might be used to accelerate improvement and suggest near-term roles for the federal government. The Framework is intended to inform the development of strategies, policies and practices for transformation of the system." (#3) 

The recently released Scorecard measures the U.S. health system on 37 key indicators and assesses how well the system is performing as a whole, relative to what is achievable. It provides benchmarks for the nation and a mechanism for monitoring changes over time across core health care system goals of health outcomes, quality, access, efficiency, and equity. Scores come from ratios that compare the U.S. national average performance to benchmarks, which represent top performance. By showing the gaps between national performance and benchmarks that have been achieved, the Scorecard offers performance targets for improvement and it provides a foundation for the development of public and private policy action. (#6) 

The Fund anticipates that the "Commission's work will be pivotal in moving the nation toward a high performance health system, one that offers better access, improved quality, and greater efficiency to all Americans." (#1)

Type of incentives

Both financial and non-financial incentives will be considered to expand access, improve quality and efficiency.

Groups affected

Consumers, providers, payers, purchasers, policymakers

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

While commissions and advisory panels have been formed in the past to explore issues and priorities within the U.S. health system, the Commission on a High Performance Health System is unique in that its Commissioners "represent broad interests in health care and a commitment to each of the elements of a high-performance health system-coverage, quality, and efficiency." (#8)

Using a national Scorecard for comprehensively measuring and monitoring health care outcomes, quality, access, efficiency, and equity in one place is also a major innovation of the Commission on a High Performance Health System. (#6)

According to the first Scorecard report, "by assessing the nation's health care against achievable benchmarks, the Scorecard, in a sense, tracks the vital signs of our health system. With rising costs and deteriorating coverage, leadership to transform the health system is urgently needed to secure a healthy nation." (#6) It is anticipated that the Commissioners will be able to provide this leadership, with support from the Commonwealth Fund, to represent their broad interests in health care and attain its vision of a high performance health system.

Political and economic background

High costs, high variability in quality of care and an increasing number of uninsured

According to Commonwealth Fund President Karen Davis, "More and more people are facing problems with their health care-higher costs, unmanageable bills, medical errors, and loss of coverage. Americans want and expect more than the inefficient, uncoordinated care they all too often experience. It's time to push for the excellence that's achievable with the resources we now devote to health care." (#7) 

According to the results from the Scorecard, "Although national health spending is significantly higher than the average rate of other industrialized countries, the U.S. is the only industrialized country that fails to guarantee universal health insurance and coverage is deteriorating, leaving millions without affordable access to preventive and essential health care. Quality of care is highly variable and delivered by a system that is too often poorly coordinated, driving up costs, and putting patients at risk." (#6) 

2005: Establishment of the Commission on a High Performance Health System

These factors led the Commonwealth Fund's Board of Directors to launch the Commission on a High Performance Health System in April 2005. The Commission "seeks opportunities to change the delivery and financing of health care to improve system performance, and will identify public and private policies and practices that would lead to those improvements. It also explores mechanisms for financing improved health insurance coverage and investment in the nation's capacity for quality improvement, including reinvesting savings from efficiency gains." (#7) 

The patients' point of view

Further supporting the impetus for the work of the Commission, Harris Interactive, on behalf of the Commonwealth Fund, surveyed U.S. adults in June 2006 to determine the public's perspectives on fixing the health care system and health policy priorities facing the President and Congress. "Overall, the representative sample of 1,023 adults ages 18 and older revealed strong public support for efforts to improve care coordination and access to information. There is a shared belief that expanded use of information technology, care teams, and improved delivery of preventive services could improve the quality of care. Patients reported recent experiences of wasteful, inefficient, or unsafe care. In addition, half of middle-income and lower-income families reported serious problems paying for care and insurance coverage. Three-quarters of all adults said the U.S. health care system needs either fundamental change or complete rebuilding. Expanding insurance and controlling costs, they said, should be top priorities for federal action."  (#2) 

Need for better organization and integration of care

The Commission has asserted that "systems with some degree of organization and cohesion are necessary as a base upon which to build an American health system adequate for the next century. These systems can take a number of forms, including, but not limited to tightly integrated systems, organized networks of physicians and hospitals, large medical group practices, or more loosely affiliated networks of rural hospitals and physicians achieving virtual integration through advanced information technology." (#7) The Commission will explore alternative models and organizational structures for setting and updating the national strategy and for measuring/tracking performance. (#3)

Change based on an overall national health policy statement

Policy changes are anticipated to occur in response to the Commission's findings and its demand for "an accelerated rate of innovation and improvement" (#3), but will take a period of time for implementation to occur.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The Commonwealth Fund's Board of Directors launched the Commission on a High Performance Health System in April 2005. 

The 19 Commission members include the following:

James J. Mongan, M.D. (Chair), Partners HealthCare System, Inc.
Maureen Bisognano, Institute for Healthcare Improvement
Christine K. Cassel, M.D., American Board of Internal Medicine and ABIM Foundation
Michael Chernew, Ph.D., Department of Health Care Policy, Harvard Medical School
Patricia Gabow, M.D., Denver Health
Robert Galvin, M.D., Director, Global Health, General Electric Company
Fernando A. Guerra, M.D., M.P.H., San Antonio Metropolitan Health District
George C. Halvorson, Kaiser Foundation Health Plan Inc.
Robert M. Hayes, J.D., Medicare Rights Center
Glenn M. Hackbarth, J.D.
Cleve L. Killingsworth, Blue Cross Blue Shield of Massachusetts
Sheila T. Leatherman, School of Public Health, University of North Carolina
Gregory P. Poulsen, M.B.A., Intermountain Health Care
Dallas L. Salisbury, Employee Benefit Research Institute
Sandra Shewry, State of California Department of Health Services
Glenn D. Steele, Jr., M.D., Ph.D., Geisinger Health System
Mary K. Wakefield, Ph.D., R.N., Center for Rural Health, University of North Dakota
Alan R. Weil, J.D., M.P.P., National Academy for State Health Policy
Steve Wetzell, HR Policy Association

The "Framework for a High Performance Health System" report released in August 2006 from the Commonwealth Fund Commission on a High Performance Health System states that there are concrete steps that could be taken to improve value, for example:

• Implementing major known quality and safety improvements;
• expanding the use of information technology;
• rewarding performance for quality and efficiency through our payment  systems;
• increasing public reporting on quality and costs; and
• importantly, expanding health insurance coverage. (#3) 

The Commission also finds that central to implementing these changes is the need to establish more organized systems of care so that individual practitioners and hospitals can have:

• A structure within which to implement known quality and safety improvements;
• a structure to invest in and support appropriate information technology advances;
• a sufficiently broad base to enter into pay-for-performance contracts which reward quality and efficiency;
• the ability to provide reliable and objective public comparison of results among systems and providers; and
• the ability to care for patients across a range of needs for acute and chronic services. (#3)

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Kostenträger

• Patienten, Verbraucher

• Andere

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Else - The Commission report considers a range of innovations to be phased in on both a small & large scale across the sectors involved in the delivery of health services.

Stakeholder positions

The Commission "asserts that the mix of private and public financing, organization and delivery will continue for the foreseeable future and calls for greater integration and alignment of incentives, while retaining pluarlism" (#3) and calls for increased stakeholder accountability within the system: "for example, health plans should be accountable for ensuring that benefits 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. For each stakeholder, there needs to be a balance in which autonomy and choice foster innovation and efficiency, but also where greater accountability reduces mortality, morbidity and costs." (#3) This is an area in which the Commission will be providing specific recommendations on how to address and to reconcile differing positions among the stakeholders that are described in more detail in the following:

• Government: The current administration and Congress have not initiated any wide-sweeping reforms given the present political climate, but rather taken a more incremental approach. Less comprehensive and less inclusive reforms such as the Medicare Part D prescription drug benefit and support of high-deductible Health Savings Accounts have attempted to address some of the gaps in coverage and access in the U.S. health care system.
• Providers: While many providers believe the health system is in need of reform, it is also expected that there will be mixed reactions to the recommendations made by the Commission and on how the recommendations are to be implemented. The Commission "anticipates that realizing its vision will require significant departures from current practice." (#3)
• Payers: While many payers also believe the health system is in need of reform, it is anticipated that there will be mixed reactions to the recommendations made by the Commission and on the recommendations for changes to financing as well. Variations in receptivity will exist among insurance companies, employers (who are increasingly experiencing a financial strain in providing health insurance for their employees), and the Centers for Medicare and Medicaid Services (CMS), who are currently running demonstrations looking at aligning payments to quality.) 
• Patients / Consumers: Given the opportunity to receive better quality of care, increased access, and greater transparency and reporting on quality and costs, patients are expected to be receptive of the proposals and reforms anticipated from the Commission's work. 
• Others: The key actors are the initiators of the innovation: The Commonwealth Fund-- a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults-- the Fund's Board of Directors who launched the Commission, its executive leadership supporting the work of the Commission, and the 19-member Commission who represent key stakeholders in the health system. By engaging these stakeholders to formulate and inform the Commission's work, it is expected that buy-in for the proposed reforms can be won. 

Actors and positions

Regierung
Government	sehr unterstützend		stark dagegen
Leistungserbringer
Providers	sehr unterstützend		stark dagegen
Kostenträger
Insurance companies	sehr unterstützend		stark dagegen
Employers	sehr unterstützend		stark dagegen
CMS	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patients	sehr unterstützend		stark dagegen
Andere
The Commonwealth Fund (Board of Directors and Executive Leadership)	sehr unterstützend		stark dagegen
The Commissioners	sehr unterstützend		stark dagegen

Influences in policy making and legislation

It is not clear at the present time what the impact of the Commission's work will be; however, it is anticipated that the Commission's findings and reports will generate increased momentum for legislation that could ultimately lead to significant reforms of the health system. The work of the Commission, however, seeks to engage both the public and private sectors in its realization of a high performance health system for the United States.

Legislative outcome

pending

Actors and influence

Regierung
Government	sehr groß		kein
Leistungserbringer
Providers	sehr groß		kein
Kostenträger
Insurance companies	sehr groß		kein
Employers	sehr groß		kein
CMS	sehr groß		kein
Patienten, Verbraucher
Patients	sehr groß		kein
Andere
The Commonwealth Fund (Board of Directors and Executive Leadership)	sehr groß		kein
The Commissioners	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

See section "Main actors".

Monitoring and evaluation

The Commission will "use the Scorecard to monitor change over time, issuing annual updates, in addition to policy reports to identify public and private policies and practices that would lead to health system improvements." (#9)

Methodology

To develop the Scorecard, researchers used the Institute of Medicine's framework for quality of care, and drew on indicators developed by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality (AHRQ), the National Committee for Quality Assurance (NCQA), and other experts. The report also includes many new indicators developed for the Scorecard, including efficiency indicators, and is the first to combine indicators for quality, access, efficiency, and equity in one scorecard. Indicators were selected based on areas of concern to the public and policymakers, where improvement could make a significant difference and where data were available with potential for time trends. (#9)

Review mechanisms

Halbzeitevaluation

Dimensions of evaluation

Struktur, Ergebnis

Results of evaluation

The findings from the first Scorecard recently released by the Commission indicate that "the U.S. falls short on what is achievable on all major dimensions of health system performance. Each statistic- each gap in actual versus achievable performance- represents illness that can be avoided, deaths that can be prevented, and money that can be saved or reinvested." (#6)

Full findings, results and implications of the Scorecard can be found in "The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 2006" and are discussed in a Health Affairs web exclusive (#10)

Expected outcome

The Commission's recently released "Why Not the Best? Results from a National Scorecard on U.S. Health System Performance" report cited the following themes, around which the Commission's ongoing work will be structured. These reflect its objective for transforming the U.S. health care system and having impact (#6):

• Universal coverage and participation are essential to improve quality and efficiency, as well as access to needed care.
• Quality and efficiency can be improved together; the U.S. must look for improvements that yield both results. Preventive and primary care quality deficiencies undermine outcomes for patients and contribute to inefficiencies that raise the cost of care.
• Failures to coordinate care for patients over the course of treatment put patients at risk and raise the cost of care. Policies that facilitate and promote linking providers and information about care will be essential for productivity, safety, and quality gains.
• Financial incentives posed by the fee-for-service system of payment as currently designed undermine efforts to improve preventive and primary care, manage chronic conditions, and coordinate care. The U.S. health system must develop payment incentives to reward more effective and efficient care, with a focus on value.
• Research and investment in data systems are important keys to progress. Investment in, and implementation of, electronic medical records and modern health information technology in physician offices and hospitals is low-leaving physicians and other providers without useful tools to ensure reliable high quality care.
• Savings can be generated from more efficient use of expensive resources including more effective care in the community to control chronic disease and assure patients timely access to primary care. The challenge is finding ways to re-channel these savings into investments in improved coverage and system capacity to improve performance in the future.
• Setting national goals for improvement based on best achieved rates is likely to be an effective method to motivate change and move the overall distribution to higher levels. (#6)

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

It is too early to judge the impact.

References

Sources of Information

• (#1) www.cmwf.org, Programs and Grants, Program Areas: A High Performance Health System: Commission on a High Performance Health System
• (#2) "In the Literature" summary by D. Lorber for, A. K. Gauthier, K. Davis, and S. C. Schoenbaum, "Achieving a High Performance Health System: High Reliability Organizations Within a Broader Agenda," Health Services Research, August 2006
• (#3) The Commonwealth Fund Commission on a High Performance Health System, "Framework for a High Performance Health System for the United States," The Commonwealth Fund, August 2006
• (#4) A. K. Gauthier, K. Davis, and S. C. Schoenbaum, "Achieving a High Performance Health System: High Reliability Organizations Within a Broader Agenda," Health Services Research, August 2006
• (#5) C. Schoen, S. K. H. How, I. Weinbaum, J. E. Craig, Jr., and K. Davis, "Public Views on Shaping the Future of the U.S. Health Care System," The Commonwealth Fund, August 2006
• (#6) The Commonwealth Fund Commission on a High Performance Health System, "Why Not the Best? Results from a National Scorecard on U.S. Health System Performance," The Commonwealth Fund, September 2006
• (#7) www.cmwf.org, Press Release: "Commonwealth Fund Commission Says the U.S. Health Care System Needs Thorough Transformation to Deliver Real Value," released August 2, 2006
• (#8) www.cmwf.org, Press Release: "New Commission on a High Performance Health System", released June 1, 2005
• (#9) www.cmwf.org, Press Release: "New National Scorecard: U.S. Health Care System Gets Poor Scores on Quality, Access, Efficiency, and Equity," released September 20, 2006
• (#10) C. Schoen, K. Davis, S.K. How, S.C. Schoenbaum U.S. Health System Performance: A National Scorecard, Health Affairs, published online September 20, 2006.

Author/s and/or contributors to this survey

Jennifer Fenley

Reviewed by Cathy Schoen and Robin Osborn, The Commonwealth Fund

Empfohlene Zitierweise für diesen Online-Artikel:

Jennifer Fenley. "Commission on a High Performance Health System". Health Policy Monitor, October 2006. Available at http://www.hpm.org/survey/us/c8/1