Ensuring that all health care providers— from physician practices to nursing homes—are responsive to the needs and preferences of patients is one of the key components of high performance and a central goal of The Commonwealth Fund. Photo: Roger Carr THE COMMONWEALTH FUND 2006 Annual Report Working toward the goal of a high performance health care system for all Americans, the Fund builds on its long tradition of scientific inquiry, a commitment to social progress, partnership with others who share common concerns, and the innovative use of communications to disseminate its work. The 2006 Annual Report offers highlights of the Fund’s activities in the past year • The Best Health System in the World. In her essay, Commonwealth Fund president Karen Davis discusses the results of the National Scorecard on U.S. Health System Performance and highlights innovations at home and abroad that offer useful roadmaps for change. 1 • The Fund’s Mission, Goals, and Strategy • Commission on a High Performance Health System • Program Highlights, 2006 - The Future of Health Insurance - State Innovations - Medicare’s Future - Health Care Quality Improvement and Efficiency - Patient-Centered Primary Care Initiative - Special Populations - International Program in Health Policy and Practice • The Commonwealth Fund Performance Scorecard. Executive vice president and chief operating officer John E. Craig, Jr., discusses the “balanced scorecard” adopted by the Fund to measure organizational effectiveness, clarify goals and strategies, and ensure continued high performance. • Treasurer’s Report and Financial Statements • The Fund's Founders and Benefactors • Directors and Staff • Grants Approved, 2005–2006 2 Photo: Roger Carr Karen Davis President’s Message 2OO6 ANNUAL REPORT The Best Health System in the World ith some of the best-equipped analyze promising approaches being used across the hospitals and most highly country and around the world. Later in its tenure, W specialized physicians in the world, the Commission will recommend immediate and it is no wonder that many people believe the U.S. long-term practical steps and policy measures. health system is the best on earth.The evidence, In the sections that follow, I review the however, suggests this confidence is misplaced. scorecard’s main findings to highlight where our According to the National Scorecard on U.S. current health system falls short; discuss the central Health System Performance, the United States scored messages that emerge; and, aided by real examples just 66 out of 100 when comparing the nation’s of high-performance health care, outline a blueprint average performance on three dozen indicators for change. against benchmarks set either within the U.S. or abroad. Given America’s high standards—and high Scores: Dimensions of a high performance health system spending on health care—that is simply unacceptable. Long, healthy & The national scorecard is the creation of the 69 productive lives Commonwealth Fund Commission on a High Quality Performance Health System. Established in July 2005, 71 the Commission seeks to move the nation toward a Access 67 system of care affording better access, higher quality, Efficiency and greater efficiency for all members of society, 51 including the most vulnerable.With the release of Equity 71 the scorecard in September 2006, the Commission OVERALL 66 has made substantial progress in meeting a primary SCORE objective—setting realistic benchmarks and targets 080 to track change over time.The coming year will be % devoted to a fact-finding process to identify and Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. 3 PRESIDENT’S MESSAGE 2006 WHAT’S WRONG: A SNAPSHOT scorecard includes indicators of mortality, healthy The Commission’s scorecard on U.S. health system life expectancy, and health-related limitations faced performance focuses on five core goals: by children and adults. Poorer Health Outcomes, Higher Mortality. Across O Long, healthy, and productive lives; five indicators of health outcomes, the U.S. scores O High-quality care; 69 compared with the benchmark performance of O Access for all; 100. On no indicator of health outcomes is the U.S. the best.The traditional excuse—that the U.S. O Efficient care; and population is “different”—is not convincing.The O Equitable care. indicators were selected to focus on the effect of The scorecard’s data highlight areas within each the health care system, not on health outcomes category where the U.S. health system currently primarily related to socioeconomic determinants of falls short. health or health behaviors such as smoking or diet. One indicator, for example, focuses on mortality LONG,HEALTHY, AND PRODUCTIVE LIVES from conditions “amenable to health care”—a The overriding expectation for a health system is measure of death rates before age 75 from diseases that it ensures the opportunity for a long, healthy, and conditions that are preventable or treatable with and productive life for everyone.The Commission timely, effective medical care.The U.S. ranked 15th Mortality amenable to health care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care Deaths per 100,000 population* International variation, 1998 State variation, 2002 150 134 129 130 132 119 115 115 109 109 110 106 107 103 97 97 99 92 100 88 88 88 90 81 84 84 75 50 0 U.S. 10th 25th Med- 75th 90th Italy JapanSpain avg ian France CanadaNorway Greece Austria FinlandIreland Sweden Australia Germany Denmark Portugal Netherlands New ZealandUnited States Percentiles United Kingdom * Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease. Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003); State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology. Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. 4 THE BEST HEALTH SYSTEM IN THE WORLD out of 19 countries, with a death rate 30 percent Too Little Preventive Care. Slightly less than half higher than France, Japan, and Spain. of U.S. adults are up-to-date with preventive care Yet hidden in these sobering findings is a glimmer recommended by the U.S. Preventive Services Task of hope: if all U.S. states performed at the same level Force. Not surprisingly, the poor and uninsured as the five best performing states, the U.S. would be figure prominently in this group, but even among on a par with the best countries. Spreading proven adults earning four times the poverty rate, only 56 best practices from a few pockets of excellence to percent received appropriate preventive care. the entire U.S. health system will be a critical step in Spotty Chronic Care Management. Proper improving outcomes. management of chronic conditions is essential to good care, and is an especially important task as HIGH-QUALITY CARE the population ages.The good news is that the Ensuring that patients get the “right care” and that the proportion of the population with their diabetes care is safe, well-coordinated, and patient-centered is adequately controlled has improved modestly in the essential foundation of high-quality care. On 19 the last five years.The bad news is that this varies indicators capturing these dimensions of care, the widely, ranging from 79 percent in the best privately U.S. scored an average of 71 out of a possible 100. insured plans, to 23 percent in the bottom 10 percent of Medicaid managed care plans. Receipt of recommended screening and preventive care for adults, by family income and insurance status, 2002 Diabetic adults who have blood glucose levels under fair control, national and managed care plan type Percent of adults (ages 18+) who received all recommended screening and preventive care within a specific time frame Percent of adults with diagnosed diabetes whose HbA1c given their age and sex* level <9.0% % 90th %ile Mean 10th %ile National 49 100 89 79 77 400%+ of poverty 56 74 69 69 200% 399% of poverty 48 64 58 <200% of poverty 39 50 50 Insured all year 52 23 Uninsured part year 46 Uninsured all year 31 0 10 20 30 40 50 National Private Medicare Medicaid 0 60 (1999 2002) % Managed care plans (2004) * Recommended care includes seven key screening and preventive Note: National estimate includes ages 18+ and plan estimates include services: blood pressure, cholesterol, Pap, mammogram, fecal occult ages 18–75. blood test or sigmoidoscopy/colonoscopy, and flu shot. Data: National estimate—National Health and Nutrition Examination Data: B. Mahato, Columbia University analysis of 2002 Medical Survey (AHRQ 2005a); Plan estimates—Health Plan Employer Data and Expenditure Panel Survey. Information Set (NCQA 2005a, 2005b). Commonwealth Fund National Scorecard on U.S. Health System Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. Performance, 2006. 5 PRESIDENT’S MESSAGE 2006 Inadequate Coordination. Coordination of patient Unreliable Care and Processes. More than six years care throughout the course of treatment and across ago, the Institute of Medicine published its landmark various sites of care helps to ensure appropriate report, To Err Is Human, calling for implementation follow-up treatment, minimize the risk of error, and of systems to ensure patient safety.1 Yet,one-third prevent complications. But about a third of adults and of American patients surveyed in the Fund’s 2005 more than half of all children did not have a medical international survey said that in the last two years home with a physician who is easily accessible and a a medical mistake or a medication or lab test error central source of care and referrals to specialists. was made during their care. In order to reach the Ensuring coordination of care is especially levels of reliability achieved by the benchmark critical at the time of discharge from a hospital.The countries, Germany and the United Kingdom, the Commission’s scorecard found that patients with U.S.