Commission Goals
In establishing the Commission on a High Performance Health System in 2005, The Commonwealth Fund’s Board of Directors recognized the need for national leadership to revamp, revitalize, and retool the U.S. health care system. The Commission’s 17 members—distinguished experts and leaders representing every sector of health care, as well as the state and federal policy arenas, the business sector, and academia—are charged with promoting a highperforming health system that provides all Americans with affordable access to excellent care while maximizing efficiency in its delivery and administration. Of particular concern to the Commission are the most vulnerable groups in society, including low-income families, the uninsured, racial and ethnic minorities, the very young and the aged, and people in poor health.
The Commission’s principal accomplishments have been to highlight specific areas where health system performance falls short of what is achievable, and to recommend practical, evidence-informed strategies for transforming the system. Many of the major ideas in the Affordable Care Act—among them, new insurance market regulations, requiring everybody to have coverage, the availability of premium and cost-sharing subsidies for low- and moderateincome families, and payment and delivery system reforms—were advanced by the Commission through the reports and statements it has issued.
The Commonwealth Fund Commission on a High Performance Health System is chaired by David Blumenthal, M.D., Fund staff members Stuart Guterman, Cathy Schoen, and Rachel Nuzum serve as executive director, research director, and senior policy director, respectively.
The Issues
The United States provides some of the best medical care in the world. Yet a growing body of evidence indicates that our health care system, as a whole, comes up short compared with what is achieved not only in other industrialized nations but also in some areas within the U.S. Although the nation’s health spending is by far the highest in the world, we are the only industrialized nation that fails to guarantee universal health insurance, and millions of our citizens lack affordable access to primary and acute care. Moreover, the care that is provided is highly variable in quality and often delivered in a poorly coordinated fashion—driving up costs and putting patients at risk.
Recent health reform legislation provides policy tools that can be used to address many of these problems. In the coming year, the Commission will focus on reinforcing the principles and goals of a high performance health system, helping the nation realize the potential of health reform, and advancing the unfinished agenda to control costs, improve value, and ensure that all Americans have access to efficient, high-quality health care.
Recent Projects
Defining and Laying Out a Framework for a High Performance Health System. In its first report, Framework for a High Performance Health System for the United States (2006), the Commission outlined a vision of a uniquely American, high performance system. That report established high performance as an achievable objective for the U.S. health system and defined the key strategies necessary to reach that objective. Two years later, the report Organizing the U.S. Health Care Delivery System for High Performance highlighted the detrimental effects of the nation’s fragmented health care delivery and payment systems and offered recommendations for establishing greater coordination across providers and care settings. Among other changes, the Commission favors moving away from fee-for-service payment and toward bundled-payment methods that reward coordinated, high-value care.
Making the Case for Reform. In 2007, the Commission on a High Performance Health System released A Roadmap to Health Insurance for All: Principles for Reform, making the case for achieving universal coverage by building on the current mix of private group plans and public programs—a course of action that would retain the best features of our current system while minimizing dislocation for Americans who currently have good insurance coverage.
The Commission believes that while ensuring that all Americans have health insurance is essential, doing so is alone not enough to drive the kind of reform our health system needs. In its report A High Performance Health System for the United States: An Ambitious Agenda for the Next President (2007), the Commission discussed concrete goals—and the strategies for achieving them—that should be on the national health care agenda, including: guaranteeing affordable health insurance for all; containing growth in health care costs and reforming provider payment; fostering greater organization and integration of care delivery; speeding adoption of health IT, evidence-based medicine, and other infrastructure; and setting and meeting national goals through strong national leadership.
Tracking Health System Performance. The Commission has issued two national and two state-level scorecards for the U.S. health system. These reports take a broad look at how well the health care system is doing, where improvements are needed, and what examples of good care exist that could serve as models for the rest of the country. They look at specific issues, including: Do people have access to the health care they need? Are they getting the highest-quality care? Are we spending money and using health care resources efficiently?
The 2011 edition of the National Scorecard on U.S. Health System Performance finds that despite pockets of improvement, the United States as a whole failed to improve when compared with the top 10 percent of U.S. states, regions, health plans, or health care providers, or the top-performing countries. The scorecard measures the health system across 42 key indicators of health care quality, access, efficiency, equity, and healthy lives. In particular, the report noted significant erosion in access to care and affordability of care, as health care costs have risen far faster than family incomes.
The bright spots in U.S. performance have largely been in areas on which public reporting or collaborative improvement initiatives have focused, such as blood pressure control, hospital treatment of heart attack and pneumonia, and prevention of surgical complications, all of which have improved substantially across the country.
The Commission’s State Scorecard on Health System Performance, meanwhile, offers a metric for evaluating individual states on access to care, prevention and treatment quality, avoidable hospital use and costs, health outcomes, and equity—with the goal of spurring policymakers and private stakeholders to undertake efforts to improve their performance to benchmark levels and beyond. The second edition of Aiming Higher: Results from a State Scorecard on Health System Performance, released in 2009 along with an interactive map showing state-by-state comparisons, reported that the cost and quality of health care, as well as access to care and health outcomes, continue to vary widely.
Developing Policy Options. In its 2007 report, Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending, the Commission showed how policies that are designed to improve health system performance can also help reduce spending growth. The report estimated the likely effects of a set of specific policy options, finding that if they were to be implemented along with universal health coverage, national health expenditures would fall by $1.5 trillion over 10 years. At the same time, the nation would reap the benefits of improved access to health care, higher-quality care, and better health outcomes.
As the national health reform debate began taking shape in early 2009, the Commission unveiled an array of comprehensive insurance, payment, and system reforms that could help make affordable health coverage widely available, lead to improved health outcomes, and slow the growth of health spending by $3 trillion by the end of the next decade. Many of the policy options presented in The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way are similar to provisions later included in the Affordable Care Act.
Helping to Realize the Potential of Health Reform. One of the most important provisions in the health reform legislation was the creation of the Center for Medicare and Medicaid Innovation, which is tasked with developing and implementing new models of health care financing and delivery that will improve care and reduce cost growth. The Center will also monitor the impact of these models and help spread ones that demonstrate success. In the 2010 issue brief Developing Innovative Payment Approaches: Finding the Path to High Performance, the Commission proposed a set of principles to guide the new Innovation Center and facilitate innovation, while recognizing the need to maintain the fiscal integrity of the Medicare and Medicaid programs.
A model of health care financing and delivery reform that has attracted much attention is the accountable care organization (ACO), a group of health care providers that agree to take responsibility for the quality and cost of care delivered to a population of patients. In the 2011 report High Performance Accountable Care: Building on Success and Learning from Experience, the Commission provides a set of recommendations for ensuring the successful implementation and spread of the ACO model, which holds promise as an effective and efficient way to deliver care, especially to people with chronic or complex medical conditions.
Informing Policymakers. In addition to formulating options for improving health policy and recommendations for implementing reform, the Commission on a High Performance Health System engages and informs policymakers in the executive and legislative branches and key health care stakeholders. The Commission sponsors bipartisan briefings and meetings for members of Congress and their staff, as well as key Administration officials. Its senior policy director, Rachel Nuzum, also directs The Commonwealth Fund’s Federal and State Health Policy program and provides policymakers in the executive and legislative branches with information and technical assistance that draw upon both Commission and Fund work. In addition, staff from the Fund and the Commission are frequently called upon by federal and state legislators to lend expert testimony and assistance.
Future Directions
Even with the passage of comprehensive health care reform, the work of the Commission on a High Performance Health System is far from complete. Over the coming months and years the Commission seeks to: 1) inform implementation of the Affordable Care Act and assess its potential to move the U.S. along the path to a high performance health system; 2) help health care leaders and the American public understand the new legislation and what it means for them; and 3) lay the groundwork for future delivery system change and health policy action. In addition, the Commission will continue its efforts to assess national and state health system performance and to inform health policy at all levels.