A High Performance Health System for the United States: An Ambitious Agenda for the Next President

With the 2008 presidential election looming, health care reform has risen to the top of the domestic policy agenda. Responding to widespread public dissatisfaction with deteriorating health insurancecoverage, steadily rising premiums, and escalating health care costs, the presidential candidates have put forward significant proposals for reform. The Commonwealth Fund Commission on a High Performance Health System welcomes this development, and commends the many excellent proposals offered so far.

With some candidates calling for greater governmental leadership and others for greater reliance on the market to achieve reform goals, the campaign promises to trigger a much-needed national debate not only on the merits of different reform strategies, but on the nation's values and its commitment to helping all Americans lead healthy and productive lives. A window of opportunity appears to be opening: more than at any other point in recent history, there is agreement among key stakeholders that attaining universal coverage and reforming the delivery system are imperatives, and that "business as usual" is no longer acceptable.

The debate is in its early stages, but candidates have already outlined many worthy ideas that would move the nation a long way toward a high performance health system. However, more effort will be required over the next five years—by the end of the next president’s first term—to ensure that Americans, who already pay the most for health care, have the great health care system they deserve.

The Commonwealth Fund Commission on a High Performance Health System has defined a high performance health system as one that helps everyone, to the extent possible, lead longer, healthier, and more productive lives. To achieve such a system, four core goals must be met: access to care for all; safe, high-quality care; efficient, high-value care; and continuous innovation and improvement.

This report presents the Commission's views on what it would take for the U.S. to reach and raise benchmark levels of health system performance. These views have been shaped by analysis of the areas in which the U.S. health system performs well and where it falls short; visits to cities, states, and health care organizations that are achieving high performance; case studies providing insight on the keys to success; and analysis of proposed policies that seek to alter the financing, organization, and delivery of health care services in support of desired results.

After reviewing what the 2008 presidential candidates have endorsed to date, the Commission applauds the emphasis a number of candidates place on extending health insurance to all. The Commission has concluded that the U.S. cannot hope to have the best health system in the world until it does what every other major industrialized nation has done—provide affordable health insurance and access to care to all. Doing so is essential for enabling people to lead healthy and productive lives.

The presidential candidates have also proposed various strategies to improve health system performance. These include: adoption of electronic health information technology, to reduce errors and increase efficiency; delivery of more preventive care; better coordination of care for patients with high-cost or chronic health conditions; improved public access to information on the cost and quality of care; and greater investment in comparative effectiveness research and identification of best practices. Some of the candidates call for a stronger government role in negotiating pharmaceutical prices, removing barriers to generic drugs, and importing medications from Canada and other developed countries. Some stress the need for aligning provider incentives to reward quality care. Others focus more on providing patients with incentives and information to empower them to shop for health care more wisely.

The strategy of covering the uninsured while simultaneously improving quality and efficiency is highly welcomed; if implemented, it would move the U.S. a long way toward a high performance health system. But in the Commission's view, the next President’s agenda must reach more broadly. If we as a nation are serious about achieving such a system, a sequence of additional steps will be required over the next five years to ensure high performance and accountability throughout the health care system—from the nation's leaders to those working at frontlines of care. It will require leadership from the President and the Congress to broker differences while keeping the ultimate goal clearly in sight.

In addition to embracing coverage and access for all, it will be critical for the next President's health policy to:

• achieve sufficient cost containment to alter the trajectory of health care costs;
• organize the health system to make it easy for patients to obtain the comprehensive, coordinated care they need and for providers to practice the best of modern medicine;
• commit the money and leadership required to implement an electronic information system within a reasonable period, aiming for five years;
• establish national goals and do what it would take to reach them.

The Commission recommends an ambitious agenda for the next President and Congress, one that simultaneously addresses five key strategies for change:

1. Affordable Coverage for All. Extend comprehensive and affordable health insurance to all and ensure seamless transitions in coverage. This is critical for guaranteeing access for all Americans. Achieving comprehensive affordable coverage will require additional spending, and the Commission recommends committing sufficient financing to attain this goal. The Commission believes that the most pragmatic approach to achieving universal coverage in the near future is to have the financing be a shared responsibility of federal and state governments, employers and individual households, and other stakeholders.

• reward both high quality of care and prudent stewardship of resources, including minimizing waste through the redesign of care delivery;
• move away from the current reliance on fee-for-service payment and toward shared provider accountability for the total care of patients; and
• correct the imbalance in payments that rewards specialty care more highly than primary and preventive care, and correct the imbalance between procedural and cognitive services.

3. Accountable, Coordinated Care. Organize the health care system so that patients and families can navigate it easily and receive excellent care. Providers must be linked with each other and with hospitals, other services, and the broader community. To end the current fragmentation, waste, and complexity, physicians and other care providers should be rewarded, through financial and nonfinancial incentives, to band together into traditional or virtual organizations that can provide the support they need to practice 21st-century health care. The goal for the future should be to enable every patient to receive care from practices that are responsive to and respectful of patient needs, as well as accountable for delivering accessible, high-quality care and coordinating a wide range of health care services.

4. Aiming Higher for Quality and Efficiency. Invest in public reporting, evidence-based medicine, and the infrastructure that supports the health care system to help all providers and care systems deliver the best care possible to their patients in a culture of innovation and improvement. Implement public policies that support healthy lifestyles and make homes, communities, and workplaces healthier places. Sufficient funding and leadership should be committed to achieve, within five years, universal implementation of electronic information systems, which are integral to comprehensive systems for improving quality and efficiency. Such systems should include an electronic health record, to make patients' medical information accessible to them and to all the health care professionals providing their care, as well as medical decision support and data systems that make it possible to understand chronic diseases patterns and track provider performance.

5. Accountable Leadership. Provide the national leadership and the collaboration and coordination among private sector leaders and government officials that are necessary to set and achieve national goals for a high performance health system. A national entity should be explored as a vehicle to develop national aims for health system performance, specific priorities and targets for improvement, a system for monitoring and reporting on performance, and recommendations as to the practices and policies required to achieve those targets.

The Commission urges that coverage for all be pursued simultaneously with the initiation of reforms aimed at improving the quality of care and efficiency of the health system. Universal coverage should not be held hostage until a more efficient health system is achieved. At the same time, coverage should not be expanded without at least beginning to make the system changes necessary to achieve a level of value that is commensurate with the nation’s investment in health care. Whenever possible, we should seek synergy between expansions of coverage and enhancements to the health care delivery system by incorporating in coverage strategies policies that also address quality and efficiency. Recognizing that building on our current system of health insurance is pragmatic and minimizes dislocation for the millions of Americans who have excellent coverage, the Commission urges measures to simplify the higher administrative overhead inherent to such a system.

This report discusses 10 detailed recommendations for moving forward in these five areas (summarized in the Appendix). In taking stock of what has been proposed to date, the Commission urges all the presidential candidates to commit to making a high performance health system a priority of their administration, including obligating the resources and achieving the consensus with Congress required to make this a reality. While theCommission recognizes that some steps may need to be implemented sequentially, we believe they are all achievable in the next administration's tenure.