Opinion leaders: U.S. health system in crisis
Opinion leaders: U.S. health system in crisis
Opinion leaders from academia and research organizations; health care delivery; business, insurance and other health industry; and government and advocacy groups surveyed by the Commonwealth Fund say the U.S. health care system isn't designed to provide high-quality health care and changes must be made at the highest levels.
The 214 individuals taking part in the midyear 2007 survey gave responses that were closely aligned with principles laid out by the Commonwealth Funds' Commission on a High Performance Health System and with the views of the general public. Commonwealth Fund officials said the survey responses "indicate a growing recognition that access to care, quality of care, and the costs of care are interrelated, and that it is difficult, if not impossible, to fix one area without addressing the others. There is strong support for change both in payment and in organization of care, as well as a surprising level of support for government intervention in critical areas."
Looking ahead to the 2008 elections, health care opinion leaders say there is an opportunity to achieve significant change within our health care system. "Hopefully, our nation's leaders will seize the opportunity to give all Americans the high-performing health care system they deserve," they say.
While the respondents acknowledge that many activities are taking place to measure and improve quality of care, the U.S. is unlike many other countries in not having a single national entity charged with coordinating all the efforts and setting a quality improvement agenda for the nation. Some 56% of the experts who were surveyed supported or strongly supported creation of a new public-private agency to coordinate efforts around quality and set a national quality agenda, while only 16% said they oppose creation of such an entity.
Surveyed experts said they thought a number of strategies would be effective or very effective in improving health care quality and safety, including accelerating adoption of health information technology (66%); public reporting of provider performance on quality measures (59%); financial incentives for improved quality of care, such as pay-for-performance (51%); and stronger regulatory oversight of providers (50%).
Fee-for-service rewards quantity
One of the problems the experts noted was that the predominant method of paying for health care services remains fee-for-service, which rewards providers for the quantity of services they provide, without regard to the appropriateness, quality, or efficiency of the care. The respondents noted that pay-for-performance programs are an attempt to align payment with the quality and efficiency of care delivered and 44% of them said they support or strongly support expansion of pay-for-performance programs, with support higher among business leaders (62%) than among academic experts (41%). The Commonwealth Fund report suggests that since most pay-for-performance programs are based on a fee-for-service structure, they are relatively ineffective in promoting care coordination and efficiency, leading some policy experts to say that more fundamental payment reform is needed. One idea would be to move away from payments based solely on discrete face-to-face clinical encounters and instead to move toward bundled payment mechanisms, such as payment for episodes of care.
Some 95% of those surveyed said fundamental payment reform is needed, and only 1% said it was not necessary. Close to half of respondents (47%) said that while fundamental payment reform is needed, the pay-for-performance programs now in place represent an important transitional step, while 25% believe that current pay-for-performance programs are an unnecessary distraction to reform efforts.
Health care opinion leaders surveyed agree with the Commission on a High Performance Health System that a much greater degree of provider organization is critical to achieving improvements in quality and efficiency. Some 73% said they support efforts to foster integration of individual providers, with half indicating they strongly support such efforts.
Potential barriers to integrating providers cited included the culture of physician autonomy (79%), a lack of financial incentives for integration (69%), and current laws and regulations (35%). Only 14% thought consumer resistance would be a major barrier.
Medical homes supported
The commission strongly supports development of medical homes for people and the opinion leaders agree. Some 66% said they support or strongly support giving Medicare beneficiaries a financial incentive, such as a reduction in Part B premiums, to register with a medical home. And 73% of respondents support reforming Medicare payment policy to encourage medical homes (currently, Medicare does not pay for providing patient-centered services such as care coordination).
The health care opinion leaders said expansion of health information technology is the most promising tool for improving quality and safety. Advanced health information systems that provide clinicians with decision-support tools and enable them to assess and monitor care can improve patient outcomes and foster more innovative, efficient use of resources, they said. But at present, only 19% of U.S. primary care doctors have advanced information capacity in their practice, compared with more than 80% of primary care doctors in the UK and the Netherlands.
Feds should take lead
Because the price tag for a significant expansion of health information technology is so high, 70% of opinion leaders surveyed said the federal government should play a leading role in assisting providers in financing health information technology, while 59% said pay-for-performance bonuses should be linked to using health information technology. Nearly 90% said that Medicare should require use of electronic medical records for all Medicare participating providers in either the next five or 10 years.
Although many health information exchange networks are emerging throughout the country, almost none have established a business model for sustained operations. Some 42% of respondents said the government should help finance development and ongoing operations of the networks, while 52% said that private insurers and payers should help finance network development and maintenance. Only 7% of respondents said government should not help finance health information exchange networks at all, and only 8% think private insurers and payers should not help finance them.
Safety bill not strong enough
Health care opinion leaders are skeptical that the Patient Safety and Quality Improvement Act of 2005 will be effective. The act calls for voluntary and confidential reporting of actions that adversely affect patients to patient safety organizations that would analyze the data and help providers implement measures to improve patient safety. Only 7% of respondents said the act is sufficient as written to improve patient safety. Some 75% believe that reporting to patient safety organizations should not be voluntary, and 60% believe that information about patient safety events should not be confidential. Interestingly, respondents who are engaged in health care delivery were least likely to be comfortable with mandatory participation in patient safety organizations (55%) and public reporting of patient safety events (31%).
Download the issue brief reporting survey results at www.commonwealthfund.org/publications/publications_show.htm?doc_id=511967.Opinion leaders from academia and research organizations; health care delivery; business, insurance and other health industry; and government and advocacy groups surveyed by the Commonwealth Fund say the U.S. health care system isn't designed to provide high-quality health care and changes must be made at the highest levels.
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