July 2010 Data Brief Commission on a High Performance Health System Health Care Opinion Leaders’ Views on Delivery System Innovation and Improvement K ristof S tremikis , K aren D avis , and A nne -M arie A udet The mission of The Commonwealth ABSTRACT: Nearly nine of 10 leaders in health care and health care policy believe cur- Fund is to promote a high performance rent financial interests and lack of incentives for integration are significant barriers to the health care system. The Fund carries growth of accountable care systems. The latest Commonwealth Fund/Modern Healthcare out this mandate by supporting independent research on health care Health Care Opinion Leaders Survey finds strong majorities of leaders report that provid- issues and making grants to improve ing special payment arrangements and incentives to providers—like those in the Patient health care practice and policy. Support Protection and Affordable Care Act—will be effective strategies for fostering coordination for this research was provided by and integration in health care delivery. More than eight of 10 leaders feel that developing The Commonwealth Fund. The views performance metrics, implementing provisions to increase transparency and public report- presented here are those of the authors ing, and establishing an Innovation Center within the Centers for Medicare and Medicaid and not necessarily those of The Commonwealth Fund or its directors, Services should receive high priority from the Secretary of Health and Human Services. officers, or staff. Survey respondents support development of a national accreditation system for account- able care organizations and public utility-type regulation of payment rates in areas with insufficient market competition.      Overview For more information about this study, please contact: As part of a strategy for reforming the U.S. health care system, several provi- Kristof Stremikis, M.P.P. sions in the recently enacted Patient Protection and Affordable Care Act promote Research Associate delivery system innovation and improvement through more coordinated and The Commonwealth Fund 1 ks@cmwf.org accountable care delivery models. Major initiatives include incentives for pro- viders to organize themselves and share savings under an accountable care orga- nization (ACO) program, deliver care via the patient-centered medical home 2 model, and receive bundled and global payments for acute and post-acute care. Such methods can improve clinical quality of care, better control chronic disease, To learn more about new publications when they become available, visit the increase patient satisfaction, and reduce hospitalizations, emergency visits, and Fund's Web site and register to receive 3 prescription drug expenses. Fund e-mail alerts. In the latest Commonwealth Fund/Modern Healthcare Health Care Commonwealth Fund pub. 1428 Vol. 92 Opinion Leaders Survey, leaders in health care and health policy were asked 2T he  C ommonwealth F und their views on barriers to such delivery system innova- These views are in line with the recommenda- tion and strategies for fostering more accountability tions of the Commonwealth Fund Commission on a and coordination among health care providers. Nearly High Performance Health System, which has a mission nine of 10 respondents feel that current financial inter- to promote better access, improved quality, and greater 4 ests and lack of incentives are significant barriers to efficiency across the U.S. health care system. The the growth of accountable care systems. It is not sur- Commission has concluded that meaningful reform of prising, therefore, that large majorities also report that the delivery system will require new financial incen- providing special payment arrangements and incen- tives; changes to regulatory, professional, and educa- tives to providers—like those in the Affordable Care tional environments; and support for new infrastruc- 5 Act—will be essential strategies for fostering more ture. An analysis of the Affordable Care Act demon- coordination and integration. strates that the significant payment and delivery A majority of leaders support the proliferation reform provisions included in the Act utilize these of integrated models of care delivery. But they also strategies and place the nation on a path to a high per- 6 support certain safeguards, like developing measures formance health system that works for all Americans. of performance to which organizations can be held accountable, and express concerns about organizations The Health Care Opinion Leaders Survey exerting undue influence in consolidated markets. The Commonwealth Fund and Modern Healthcare More than eight of 10 leaders feel that developing per- recently commissioned Harris Interactive to solicit the formance metrics, implementing provisions to increase perspectives of a diverse group of health care experts transparency and public reporting, and establishing an on delivery system innovation and improvement. The Innovation Center within the Centers for Medicare and 225 individuals who took part in the survey—the 22nd Medicaid Services should receive high priority from in a continuing series of surveys assessing the views of the Secretary of Health and Human Services in the experts on key health policy issues—represent the next one to two years. Survey respondents also support fields of academia and research; health care delivery; development of a national accreditation system for business, insurance, and other health industries; and accountable care organizations and public utility-type government, labor, and advocacy groups (see regulation of payment rates in areas where there is Methodology, Appendix A). Respondents were asked insufficient market competition. for their perspective on delivery system innovation and improvement between June 8, 2010, and July 7, 2010. A bout the H ealth C are O pinion L eaders S urvey The Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey was conducted online within the United States by Harris Interactive, on behalf of The Commonwealth Fund, between June 8, 2010, and July 7, 2010, among 1,330 opinion leaders in health policy and innovators in health care delivery and finance. The final sample included 225 respondents from various industries, for a response rate of 17 percent. Data from this survey were not weighted. A full methodology is available in Appendix A. H ealth C are O pinion L eaders ’ V iews on D elivery S ystem I nnovation and I mprovement 3 Opinion leaders believe integrated delivery systems Exhibit 1. Barriers to Growth of Accountable Care Systems “In your view, how significant are the following barriers to growth of will be an effective model for moving the U.S. health population-based, accountable care systems?” system toward more accountable care. Extremely significant Very significant Opinion leaders were asked to rate the effec- Current financial interests and incentives of health care providers, 64 29 93% tiveness of several reform models designed to move suppliers, and other stakeholders the U.S. health system toward more accountable care, Lack of financial incentives 45 41 86% many of which were included in the recently enacted for integration Lack of alignment of public and health reform law. A majority of respondents feel that 39 36 75% private payer policies & practices integrated delivery systems (64%) and accountable Culture of physician autonomy 30 41 71% care organizations (54%) will be either very effective or extremely effective reform models (Exhibit 2). Less The way in which providers are currently trained 24 37 61% than half of leaders rate networks or partnerships Availability of technical assistance to among organizations delivery services across the con- undergo necessary transformation 14 38 52% tinuum of care (40%) and patient-centered medical Patient preference for open 13 39 51% homes (39%) as effective. access to providers and services 0 20 40 60 80 100 * Percentages may not be equal to the net because of rounding. Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010. Exhibit 2. Effectiveness of Reform Models “Overall, how effective do you feel each of the following reform Nearly nine of 10 survey respondents think current models will be in moving the U.S. health system toward population-based, coordinated, accountable care?” financial interests and lack of incentives for integra- tion are significant barriers to the growth of account- Extremely effective Very effective able care systems. Commonwealth Fund research has shown that Integrated delivery systems 22 42 64% misaligned financial incentives and fragmented pay- Accountable Care ment methods foster similar fragmentation and lack of Organizations 13 41 54% coordination in the delivery and receipt of health care 5 Networks or partnerships 7 in the United States. Ninety-three percent of opinion among organizations delivering 8 31 40% services across the continuum leaders believe that current financial interests of health Patient-centered medical care providers, suppliers, and other stakeholders are a homes with shared resources 11 28 39% and services significant barrier to the growth of more accountable * Percentages may not be equal to the net because of rounding. care systems (Exhibit 1). Lack of financial incentives Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010. for integration (86%), misalignment of public and pri- vate payer policies and practices (75%), and a culture of physician autonomy (71%) were also identified by Strong majorities of health care opinion leaders feel more than seven of 10 respondents as hindering the that providing special payment arrangements and spread of more population-based, accountable care financial incentives to providers will be effective strat- models. The availability of technical assistance to egies for fostering accountability. undergo necessary transformation (52%) and patient The Affordable Care Act includes numerous preferences for open access to providers and services payment and system reform provisions designed to (51%) are also viewed as barriers by a majority realign incentives and encourage providers to deliver of leaders. high-quality, patient-centered care. Sixty-five percent of survey respondents believe that providing special payment arrangements to accountable care systems 4T he  C ommonwealth F und Exhibit 3. Strategies to Foster Accountability, Exhibit 4. Importance of Affordable Care Act Provisions Coordination, and Integration “The U.S. Department of Health and Human Services will need to implement “Policymakers have proposed several levers to foster accountability, numerous provisions of the Affordable Care Act. In setting priorities for coordination, and integration among providers who are responsible for Secretarial attention, please rate the importance of each of the following providing care to a given population of patients. Please rate the effectiveness strategies in the short term (next one to two years).” of the following strategies.” Very important Important Extremely effective Very effective Development of ACO 31 57 88% Provide special payment metrics of performance arrangements to accountable 26 39 65% care systems Increasing transparency and public reporting on quality of care, 38 44 81% resource use, and costs Give providers financial 21 43 65% incentives to practice in ACOs Establishment of the CMS Innovation Center and launch of 45 34 80% Give patients financial innovative payment pilots incentives to join 10 41 51% Creation of a Patient-Centered 31 44 75% accountable care systems Outcomes Research Institute Provide infrastructure support Establishment of ACO eligibility criteria for 17 33 50% 27 47 74% to spur development of ACOs shared savings payment under Medicare Alignment of ONCHIT funding and technical Require patients to join assistance to support the development of 23 49 72% accountable care systems 10 24 34% population-based accountable care systems Require providers to practice in Establishment of the Independent 32 34 67% accountable care systems subject 7 26 33% Payment Advisory Board to meeting eligibility requirements 0 20 40 60 80 100 and inclusion criteria * Percentages may not be equal to the net because of rounding. 0 10 20 30 40 50 60 70 80 Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, * Percentages may not be equal to the net because of rounding. July 2010. Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010. and giving providers financial incentives to practice in the importance of these initiatives. More than eight of ACOs will be very or extremely effective strategies to 10 respondents identify development of performance foster accountability, coordination, and integration in metrics for accountable care systems (88%), imple- care delivery (Exhibit 3). About half of opinion leaders mentation of provisions to increase transparency and feel that giving patients incentives to join accountable public reporting (81%), and establishment of the care systems (51%) and providing infrastructure sup- Innovation Center within the Centers for Medicare and port to spur development of ACOs (50%) will be Medicaid Services (80%) as either important or very effective strategies; only one-third of leaders believe important priorities (Exhibit 4). Creation of a Patient- requiring patients (34%) or providers (33%) to join Centered Outcomes Research Institute (75%), estab- or practice in accountable care systems will be effec- lishment of eligibility criteria for ACOs (74%), and tive strategies for fostering more accountability in alignment of health information technology funding care delivery. and technical assistance to support accountable care systems (72%) are also seen as important priorities by Leaders feel that development of performance metrics, large majorities of respondents. implementation of provisions to increase transparency and public reporting, and establishment of the Innovation Center within the Centers for Medicare and Medicaid Services should receive high priority. The U.S. Department of Health and Human Services will need to implement numerous provisions of the Affordable Care Act designed to facilitate deliv- ery system innovation and improvement in the coming years. Health care opinion leaders were asked to rate H ealth C are O pinion L eaders ’ V iews on D elivery S ystem I nnovation and I mprovement 5 Exhibit 5. Support for Development of National Exhibit 6. Support for Primary Care Foundation for ACOs ACO Accreditation System “Some experts have advocated requiring a strong primary care foundation for “Some policymakers have advocated for an accreditation process for Accountable Care Organizations (ACOs). Please indicate the degree to which accountable care systems. Please indicate the degree to which you support or you support or oppose establishing standards for primary care capacity as a oppose developing a national accreditation system for such organizations.” condition for qualifying for ACO payment.” Strongly Not sure Oppose Strongly oppose 4% oppose Not sure 7% 3% 2% 1% Oppose 26 Neither 26 9% support Strongly nor oppose support 12% 21 22% 21 Strongly Neither support support 10 10 46% nor oppose 20% 17 17 10 10 Support Support 31% 41% 7 7 * Percentages may not be equal to 100 percent because of rounding. * Percentages may not be equal to 100 percent because of rounding. Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010. July 2010. Sixty-three percent of survey respondents support Nearly three-quarters of opinion leaders are con- development of a national accreditation system cerned about undue market power and dominance for ACOs. among provider groups. The Affordable Care Act includes require- Many of the payment and delivery system ments for organizations who wish to participate in new reform initiatives contained in the Affordable Care Act ACO pilot programs. But some policymakers have are designed to move the U.S. health care system advocated for a more comprehensive and formal toward population-based, accountable care systems. accreditation process for ACOs. Formal accreditation Leaders were asked about their concerns regarding could help ensure that organizations receiving account- market power and dominance among provider groups. able care payments possess sufficient infrastructure Nearly three-quarters (74%) of opinion leaders said and have defined processes for delivering high-quality, they are concerned or very concerned (Exhibit 7). integrated care. Sixty-three percent of opinion leaders Concerns are consistent among leaders across respon- support or strongly support development of a national dent categories, including business, insurance, and accreditation system for ACOs (Exhibit 5). other health care industries (Table 6). Nearly eight of 10 leaders support or strongly support A majority of respondents favor public utility regula- standards for primary care capacity in ACOs. tion of ACO payment rates in areas with insufficient Respondents were asked to indicate the degree market competition. to which they support or oppose establishing standards Given the significant concern about undue for primary care capacity as a condition of qualifying market power under a more consolidated system of for payment as an ACO. Nearly eight of 10 leaders care, policymakers and analysts have proposed public (77%) support or strongly support such standards utility-type regulation of ACO payment rates in areas (Exhibit 6). with insufficient market competition. Fifty-six percent 6T he  C ommonwealth F und Exhibit 7. Concern over Market Power and Dominance Exhibit 8. Support for Public Utility Regulation of ACO Payment Rates “If, as the Affordable Care Act envisions, the nation moves toward population-based accountable care systems, how much of a concern “To safeguard against undue market power, would you favor or oppose public is market power and dominance?” utility regulation of Accountable Care Organization (ACO) payment rates where there is insufficient market competition?” Very Unconcerned unconcerned 7% 2% Not sure Neither 5% Not sure concerned Strongly oppose 9% nor unconcerned 26 13% 8% 21 Strongly 21 support Oppose 21% 13% 10 10 17 Concerned Very 17 38% concerned Neither 10 37% support nor oppose 10 Support 14% 35% 7 * Percentages may not be equal to 100 pecent because of rounding. 7 Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, * Percentages may not be equal to 100 pecent because of rounding. July 2010. Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010. of leaders support or strongly support such regulation, while 21 percent oppose or strongly oppose these mea- sures (Exhibit 8). Support was higher among those in academic and research institutions (66%) and lower among those in business and industry (47%) and health care delivery (48%) (Table 8). Nearly six of 10 leaders support exempting ACOs from Exhibit 9. Support for ACO Exemptions certain requirements in exchange for meeting perfor- “Please indicate the degree to which you support or oppose exempting Accountable Care Organizations (ACOs) from the following mance, disclosure, and accreditation standards. requirements in exchange for meeting performance, reporting/disclosure, and accreditation standards.” Disclosure requirements and accreditation Strongly support Support standards may help ensure concerns about the market power of providers under more consolidated systems of care. Sixty-two percent of survey respondents Antitrust and other legal barriers to coordinating care 25 37 62% support or strongly support exempting ACOs from or sharing cost information antitrust and other legal barriers to coordinating care 5 and sharing cost information but only if ACOs meet explicit performance, disclosure, and accreditation Provider scope of practice act laws 26 30 56% standards (Exhibit 9). Support for exemptions is particularly high among leaders in health care delivery (80%) (Table 9). Overall, 56 percent of respondents * Percentages may not be equal to the net because of rounding. Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, support exempting ACOs from provider scope of July 2010. practice laws. H ealth C are O pinion L eaders ’ V iews on D elivery S ystem I nnovation and I mprovement 7 The Path to a High Performance Fortunately, many significant provisions Health System designed to foster delivery system improvement Health care opinion leaders overwhelmingly agree that through the use of more coordinated and integrated current financial interests and lack of incentives for care delivery models are included in the recently integration are significant barriers to the growth of enacted Affordable Care Act. The new law provides more accountable care systems. Large majorities report incentives for providers to organize themselves and that providing special payment arrangements and share savings under an ACO provider category, utilize incentives to providers will be effective strategies for the patient-centered medical home model, and receive fostering more coordination and integration in care bundled and global payments for acute and post-acute delivery. Leaders believe that developing performance care. Commonwealth Fund research and analyses have metrics, increasing transparency and public reporting, shown that these payment and delivery reform provi- and establishing an Innovation Center within the sions will encourage the delivery of more effective and Centers for Medicare and Medicaid Services should all efficient care, yield greater value for the nation’s health receive high priority from the Secretary of Health and spending, and place the U.S. on a path to a high per- Human Services in the short term. formance health system that works for all Americans. N otes 1 K. Davis, A New Era in American Health Care: 5 A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, Realizing the Potential of Reform (New York: The R. Nuzum, and D. McCarthy, Organizing the U.S. Commonwealth Fund, June 2010). Health Care Delivery System for High Performance 2 (New York: The Commonwealth Fund, Aug. 2008). S. Guterman, K. Davis, K. Stremikis, and H. Drake, “Innovation in Medicare and Medicaid Will Be 6 K. Davis, S. Guterman, S. R. Collins, K. Stremikis, Central to Health Reform's Success,” Health S. Rustgi, and R. Nuzum, Starting on the Path to a Affairs, June 2010 29(6):1188–93. High Performance Health System: Analysis of 3 Health System Reform Provisions of Reform Bills in D. McCarthy, K. Mueller, Organizing for Higher the House of Representatives and Senate, (New Performance: Case Studies of Organized Delivery York: The Commonwealth Fund, Jan. 2010). Systems (New York: The Commonwealth Fund, July 2009). 7 Shih, Davis, Schoenbaum, Organizing the U.S. 4 Health Care Delivery System, 2008. The Commonwealth Fund Commission on a High Performance Health System, Keeping Both Eyes on the Prize: Expanding Coverage and Changing the Way We Pay for Care Are Essential to Make Health Reform Work for Families and Businesses (New York: The Commonwealth Fund, Nov. 2009). 8T he  C ommonwealth F und A ppendix A. M ethodology This survey was conducted online by Harris Interactive on behalf of The Commonwealth Fund among 225 opinion leaders in health policy and innovators in health care delivery and finance within the United States between June 8, 2010, and July 7, 2010. Harris Interactive sent out individual e-mail invitations to the entire panel containing a password-protected link and a total of five reminder e-mails were sent to those who had not responded. No weighting was applied to these results. The initial sample for this survey was developed using a two-step process. The Commonwealth Fund and Harris Interactive jointly identified a number of experts across different professional sectors with a range of perspectives based on their affiliations and involvement in various organizations. Harris Interactive then conducted an online survey with these experts asking them to nominate others within and outside their own fields whom they consider to be leaders and innovators in health care. Based on the results of the survey and after careful review by Harris Interactive, The Commonwealth Fund, and a selected group of health care experts, the sample for this poll was created. The final list included 1,246 individuals. In 2006, The Commonwealth Fund and Harris Interactive joined forces with Modern Healthcare to add new members to the panel. The Commonwealth Fund and Harris Interactive were able to gain access to Modern Healthcare’s database of readers. The Commonwealth Fund, Harris Interactive, and Modern Healthcare identified readers in the database that were considered to be opinion leaders and invited them to participate in the survey. This list included 1,467 people. At the end of 2006, The Commonwealth Fund and Harris Interactive removed those panelists who did not respond to any previous surveys. In 2007 recruitment for the panel continued, with Modern Healthcare recruiting individuals through their Daily Dose newsletter. In addition, Harris Interactive continued to recruit leaders by asking current panelists to nominate other leaders. The final panel size for the Delivery System Innovation and Improvement survey included 1,330 leaders. With this survey we are using a new definition of the panel. Two hundred and twenty-five of these panelists com- pleted the survey, for a 17.0% response rate. With a pure probability sample of 225 adults, one could say with a 95 percent probability that the overall results have a sampling error of +/– 6.53 percentage points. However, that does not take other sources of error into account. This online survey is not based on a probability sample and therefore no theoretical sam- pling error can be calculated. The data in this brief are descriptive in nature. It represents the opinions of the health care opinion leaders interviewed and is not projectable to the universe of health care opinion leaders. H ealth C are O pinion L eaders ’ V iews on D elivery S ystem I nnovation and I mprovement 9 A bout the A uthors Kristof Stremikis, M.P.P., is senior research associate for the president of The Commonwealth Fund. Previously, he was a graduate student researcher in the School of Public Health at the University of California, Berkeley, where he evaluated various state, federal, and global health initiatives while providing economic and statistical support to faculty and postdoctoral fellows. He has also served as consultant in the director’s office of the California Department of Healthcare Services, where he worked on recommendations for a pay-for-performance system in the Medi-Cal program. Mr. Stremikis holds three undergraduate degrees in economics, political science, and history from the University of Wisconsin at Madison. In May 2008, he received a Master of Public Policy degree from the Goldman School at the University of California, Berkeley. He can be e-mailed at ks@cmwf.org. Karen Davis, Ph.D., is president of The Commonwealth Fund. She is a nationally recognized economist with a distinguished career in public policy and research. In recognition of her work, Ms. Davis received the 2006 AcademyHealth Distinguished Investigator Award. Before joining the Fund, she served as chairman of the Department of Health Policy and Management at The Johns Hopkins Bloomberg School of Public Health, where she also held an appointment as professor of economics. She served as deputy assistant secretary for health policy in the Department of Health and Human Services from 1977 to 1980, and was the first woman to head a U.S. Public Health Service agency. A native of Oklahoma, she received her doctoral degree in economics from Rice University, which recognized her achievements with a Distinguished Alumna Award in 1991. Ms. Davis has published a number of significant books, monographs, and articles on health and social policy issues, including the landmark books Health Care Cost Containment; Medicare Policy; National Health Insurance: Benefits, Costs, and Consequences; and Health and the War on Poverty. She can be e-mailed at kd@cmwf.org. Anne-Marie J. Audet, M.D., MSc., is a vice president at The Commonwealth Fund and the director of its Program on Health System Improvement and Efficiency. A leader in health care quality improvement for more than 20 years at the national, state, and provider levels, Dr. Audet has conducted policy analysis at the American College of Physicians, led the implementation of the Medicare Health Care Quality Improvement Program in Massachusetts while with the Massachusetts Peer Review Organization, and, more recently, worked with CareGroup, an integrated care system. She also has served as director of the Office for Clinical Effectiveness/Process Improvement at Beth Israel Deaconess Medical Center in Boston, with responsibility for development of quality measurement systems, educational programs, and institution-wide medication safety initiatives. In addition to serving on the Massachusetts Medical Society and Alliance Charitable Foundation board, she is on the Institute of Medicine Subcommittee on Quality Improvement Organizations’ Evaluation. Dr. Audet earned an undergraduate degree in cell and molecular biology, a medical degree, and a master’s degree in epidemiology from McGill University, as well as an S.M. in health policy and management from Harvard University. She can be e-mailed at ama@cmwf.org. Editorial support was provided by Deborah Lorber.