AcademyHealth President and CEO Lisa Simpson's presentation for the Richard and Janet Southby Distinguished Lecutreship in Comparative Health Policy at the George Washington University Hospital on April 24, 2012

1. Thinking Beyond Our Borders:
What We Can Learn about Improving
Care from Other Countries
Dr. Lisa Simpson
President and CEO
April 24, 2012

2. Outline
 Introduction
 What do international studies tell us about
health and health care in the U.S.?
 Leading Approaches in Other Countries
 Burgeoning Field of Implementation Science
 Concluding Thoughts

3. AcademyHealth: Improving
Health & Health Care
AcademyHealth is a leading national organization serving the fields of health
services and policy research and the professionals who produce and use this
important work.
Together with our members, we offer programs and services that support the
development and use of rigorous, relevant and timely evidence to:
1. Increase the quality, accessibility and value
of health care,
2. Reduce disparities, and
3. Improve health.
A trusted broker of information, AcademyHealth
brings stakeholders together to address the current
and future needs of an evolving health system,
inform health policy, and translate evidence into action.
3

4. Leveraging >4,500 Diverse,
Expert Members & Organizations
AcademyHealth Interest Groups
 Behavioral Health Services Research  Health Workforce
 Child Health Services Research  Interdisciplinary Research Group on Nursing Issues
 Disability Research  Long-Term Care
 Disparities  Public Health Systems Research
 Gender and Health  Quality & Value
 Health Economics  Translation & Communications
 Health Information Technology  State Health Research and Policy
4 3

5. Mission and Programs
Methods and professional skill-building
seminars, methods council
Address the current and
Electronic Data Methods (EDM) Forum
future needs of an Changes in Health Care Financing and
evolving health system Organization (HCFO)
Multi-payer Claims Database (MPCD)
Annual Research Meeting
AHRQ Knowledge Transfer Initiative
Beacon Evaluation and Innovation Network
Inform health policy National Library of Medicine’s HSRProj
National Health Policy Conference
Public Health Services Research
AHRQ Healthcare Innovations Exchange
State Coverage Initiatives
Translate evidence AHRQ Medicaid Medical Director’s
into action Learning Network
Advocacy and Public Policy
5

6. Conferences
 Annual Research Meeting (ARM)
– June 24-26, 2012 in Orlando, FL
– Over 2,000 attendees
 Health Policy Orientation
– October 22-25, 2012 in Washington DC
– Limited to 50 participants
 National Health Policy Conference
(NHPC)
– February 4 – 5, 2013 in DC
– Over 800 attendees

7. AcademyHealth Focus
2012-2014
 Fundamental program areas
– Generate new knowledge
– Move knowledge into action
 Strategic priority areas
– Health care costs and value
– Delivery system transformation
– Public and population health
 Push audiences
– Delivery system leaders
– States

8. ARM Opportunities for
Students
 Registration and hotel discounts
 Scholarships
 Meet-the-expert breakfast
 Networking events
 Career Coaches
 Awards for best dissertation & poster

9. Declaring My Biases!
1. The US is far too insular
in its approach to the
world!
2. There is much to be
learned from other
countries as we struggle
to improve health and
health care.
3. Others in the audience
know far more than I do!

10. Agenda
 Introduction
 What do international studies tell us about
health and health care in the U.S.?

11. Dimensions of Comparison
 Health and outcomes
 Health care costs
 Health care utilization

12. Adults Who Report Being Daily Smokers, 2009
THE
COMMONWEALTH
FUND
Percent
40
30 28.0
26.2
24.9
21.9 21.5 21.5 21.0
20.4
20 19.0 18.1
16.6 16.2 16.1
14.3
10
0
NETH FR* JPN GER UK OECD NOR SWIZ** DEN NZ** AUS** CAN US SWE
Median
* 2008.
** 2007.
Source: OECD Health Data 2011 (June 2011).

13. Obesity (BMI>30) Prevalence Among Adult Population, 2009 THE
COMMONWEALTH
FUND
Percent
40
Measured Self-reported
35 33.8
30
26.5
24.6 24.2
25 23.0
20
14.7
15
11.8 11.2 11.2
10.0
10 8.1
5 3.9
0
US* NZ** AUS** CAN* UK GER NETH FR* SWE NOR* SWIZ** JPN
Note: Body-mass index (BMI) estimates based on national health interview surveys (self-reported data)
are usually significantly lower than estimates based on actual measurements.
* 2008.
** 2007.
Source: OECD Health Data 2011 (June 2011).

14. Breast Cancer Five-Year Relative Survival Rate, THE
COMMONWEALTH
2002–2007 (or nearest period) FUND
Percent
100
90.5
87.1 86.1 85.2
82.4 82.1 81.9
80
78.5
60
40
20
0
US CAN SWE NETH DEN NZ NOR UK
Source: OECD Health Care Quality Indicators Data 2009.

15. Diabetes Lower Extremity Amputation Rates THE
per 100,000 Population Age 15 and Older, 2007 COMMONWEALTH
FUND
40
36
30
21
20
16
13
12 12 12
11 11 11
10 9
0
US* DEN SWIZ* FR NZ Median*** SWE CAN NETH** NOR UK
* 2006.
** 2005.
*** Among countries shown.
Source: OECD Health Care Quality Indicators Data 2009.

16. Mortality After Admission for Acute Myocardial Infarction*
THE
per 100 Patients, 2007 COMMONWEALTH
FUND
8
6.6
6.3
6
5.1
4.2
4
3.3 3.2
2.9 2.9
2
0
NETH** UK US* CAN NZ NOR DEN SWE
* In-hospital case-fatality rates within 30 days of admission.
** 2006.
*** 2005.
Source: OECD Health Care Quality Indicators Data 2009.

17. THE Health Spending per Capita, 2009
COMMONWEALTH
FUND Adjusted for Differences in Cost of Living
Dollars
$7,960
$8,000
$7,000
$6,000
$5,352
$5,144
$4,914
$5,000
$4,218 $4,363
$3,978
$4,000 $3,722
$3,445 $3,487
$2,983
$3,000
$2,000
$1,000
$0
NZ AUS UK SWE FR GER CAN NETH SWIZ NOR US
(10.3%) (8.7%)* (9.8%) (10.0%) (11.8%) (11.6%) (11.4%) (12.0%) (11.4%) (9.6%) (17.4%)
% GDP
* 2008.
Source: OECD Health Data 2011 (June 2011).

18. 18
Health Care Spending per Capita by Source of Funding, 2009
Adjusted for Differences in Cost of Living
Dollars
7,960
8,000
976
7,000 Out-of-pocket spending
Private spending
6,000 Public spending
5,352
3,189
5,144
5,000 808
4,363 4,218
43
1,568 3,978
4,000 636 552
3,722
291 3,487 3,445
504 646 424 587 620 2,983
69
364 627 2,878
3,000 188
399 454
476 184
4,501 99
2,000 3,795
3,072 3,081 3,242 3,100 3,033 2,935
2,342 2,400 2,325
1,000
0
US NOR SWIZ CAN GER FR SWE UK AUS* NZ JPN*
THE
COMMONWEALTH
FUND
* 2008.
Source: OECD Health Data 2011 (June 2011).

19. 19
Average Health Care Spending per Capita, 1980–2009
Adjusted for differences in cost of living
Dollars
8000 US
NOR
7000 SWIZ
NETH
6000
CAN
DEN
5000
GER
4000 FR
SWE
3000 UK
AUS
2000
NZ
JPN
1000
0
1980 1984 1988 1992 1996 2000 2004 2008
THE
COMMONWEALTH
FUND
Source: OECD Health Data 2011 (June 2011).

20. Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year
THE
COMMONWEALTH
FUND
More than US$1,000 in Serious problems paying or
out-of-pocket costs unable to pay medical bills
Percent
60
50
39
40
35 36
30 27
24
20 16
13 14
11 12 11
10 7 8 8 8
5 6 5 6
4
1 1
0
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

21. 21
Average Annual Number of Physician Visits per Capita, 2009
14 13.2
12
10
8.2
8
6.9
6.5 6.3
6 5.7 5.5
5.0
4.6 4.3 4.0 3.9
4
2.9
2
0
JPN* GER FR AUS OECD NETH CAN* UK DEN NZ** SWIZ** US* SWE
Median
THE
* 2008. COMMONWEALTH
** 2007. FUND
Source: OECD Health Data 2011 (June 2011).

22. Patients with a Regular Doctor versus a Medical Home THE
COMMONWEALTH
FUND
Has a regular doctor or place of care
Percent Has a medical home
99 99 99 99 99 97 97 100
100 96 95
91
80 74
70
65
60 56 53 52 51 49 48 48
40 33
20
0
UK SWIZ NZ US NOR FR AUS CAN GER NETH SWE
Patients with a medical home have a regular practice who is
accessible, knows them, and helps coordinate their care
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

23. Rated Quality of Care in Past Year as “Excellent” or “Very Good,” THE
by Medical Home COMMONWEALTH
FUND
Percent
100
Medical home No medical home
88
83
79 77
80
72 72
65
62 60
59 57
60 56
49
46 44 44 43
40 38
35 34
27 26
20
0
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

24. Waited Less Than a Month to See Specialist THE
COMMONWEALTH
FUND
Percent
100 92
88
81 80 79
80
68 67
63
59
60 52
47
40
20
0
SWIZ US NETH UK GER NZ FR SWE AUS CAN NOR
Base: Saw or needed to see a specialist in the past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

25. Shared Decision-Making with Specialists THE
COMMONWEALTH
FUND
Percent reporting positive shared decision-making experiences with specialists*
100
80 79
80
72
67 67 64 61
60
50 48
40 37
40
20
0
SWIZ UK NZ NETH US AUS CAN GER SWE NOR FR
* Reported specialist always/often: 1) Gives opportunities to ask questions about recommended treatment;
2) Tells you about treatment choices; and 3) Involves you as much as you want in decisions about your care.
Base: Seen specialist in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

26. Cross-Cutting Themes and Implications
 Outcomes and quality have improved but there is room for
improvement in all countries
 There is a clear need to contain public spending
 Per capita spending has risen by 70% since the early
90’s
 U.S. is an outlier on access and affordability
 Cost-sharing and benefit design matters
 Strong primary care “medical homes” make a difference in
all countries

27. Health care systems: getting more
value for money (OECD Report, 2010)
 There is no health care system that performs systematically
better in delivering cost-effective health care.
 On average, life expectancy at birth could be raised by more
than two years, while holding health care spending steady, if all
countries were to become as efficient as the best performers.
 Health outcomes are highly disparate across individuals and
such inequalities can be reduced without sacrificing efficiency
 There is no “one-size-fits-all” approach to reforming health care
systems.
 By improving the efficiency of the health care system, public
spending savings would be large, approaching 2% of GDP on
average in the OECD.

28. Outline
 Overview of AcademyHealth
 How the U.S. Compares: Quality and
Outcomes
 Leading Approaches in Other Countries

29. Strategies in Use
 OECD:
– Reliance on market mechanisms and
regulations to steer demand and
supply
– Coverage principles to promote equity
– Budget and management approaches
to control public spending

30. Market Mechanisms
 Users
– Price signals
– Gate keeping & limited choice among providers
 Providers
– Mitigating volume incentives
– Regulating prices
– Enhancing patient choice
– User information on quality and price

31. Common International Trends
 Standardizing and integrating health
information technology and other electronic
data innovations
 Bolstering the research enterprise and
integrating CER into decision-making
 Engaging patients meaningfully in their care
and shifting the perspective of research to be
patient-centered
Kalipso Chalkidou, NICE International

32. Engaging Patients
 American patients who feel engaged by their
providers are more likely to rate their care as high
quality than engaged patients in other countries
 Low income patients were less likely to feel engaged
than higher income patients
 American patients are likely to report positive care
experience, even if clinical needs were not met
 American patients exhibited the greatest disparities in
care and engagement
R. Osborn and D. Squires, "International Perspectives on Patient Engagement:
Results from the 2011 Commonwealth Fund Survey," Journal of Ambulatory Care
Management, April/June 2012 35(2):118–28.

33. Divergent Actions, Similar Trends
 Compared: OECD Health Care Quality Indicators
Project and the US National Healthcare Quality
Report
 Found:
– Choice of breadth or priorities
– Methods must be developed to both edit indicators
and preserve core set for longitudinal study
– Communication, translation, dissemination are key
– Momentum matters
Edward T. kelley 1 , 2 , Irma Arispe 3 and Julia Holmes 3
Beyond the initial indicators: lessons from the OECD Health Care Quality Indicators
Project and the US National Healthcare Quality Report
Int J Qual Health Care (September 2006) 18 (suppl 1): 45-51. doi: 10.1093/intqhc/mzl027
http://intqhc.oxfordjournals.org/content/18/suppl_1/45.long

34. US Activity vs. International
 Generate the right data and  Generate the right data and
evidence evidence
– Inform patient choice as well as – Convergence of payer and
traditional decision makers regulator use of CER
– HIT, electronic data, systematic – HIT, electronic data, systematic
reviews, real-world reviews, cost-focused analysis,
demonstrations, measure international pilots, measure
standardization/harmonization standardization/ harmonization
 Identify the right populations  Identify the right populations
and partners and partners
– Patient- centered research – Patient- centered research,
 Engage both to make more product developers, health
system professionals
informed and creative ideas
– PCORI, patient-centered  Engage both to make more
medical homes informed and creative ideas
– Value-based pricing

35.  Population Health, Patient Experience, Per
Capita Cost
 HHS implementation in the US
 IHI Triple Aim Partners 2011
– UK (NHS)
– Australia
– Sweden
– Singapore
– New Zealand
– Canada
http://www.ihi.org/offerings/Initiatives/TripleAi
m/Pages/Participants.aspx

36. Population Health is…
 …the health outcomes of a group of
individuals, including the distribution
of such outcomes within the group.
 Group can be defined by geography or
include other types such as employees,
ethnic groups, disabled persons, etc…
Source: Kindig and Stoddart. “What is Population Health?” Am J Public Health.
2003 March; 93(3): 380–383.
36

37. Population Health
 Churchill had it right!
– Americans will make the right choice, after…
 Costs have put it on the table
– Private sector focus
– ACA

38. Provisions in ACA for Population Health
 Addresses need for systematic
approach to definition, funding, evidence
base, communication, and need for
cooperation.
 The introduction of a reliable, steady
stream of funding for public health
research.
 Encourages development and use of
common metrics to measure
effectiveness.
 Promotes prevention in the health care
system
Source: Bovberg, et al. “What directions for Public Health under the
Affordable Care Act?” The Urban Institute Health Policy Center, November
2011.

39. Population Health
• “Because improvement in population health requires
the attention and actions of multiple actors
(legislators, managers, providers, and individuals),
the field of population health needs to pay careful
attention to the knowledge transfer and academic-
practice partnerships that are required for positive
change to occur.”
• Moves beyond current distinction between public
health programs & health care delivery
• Integrated approach supported by multiple aspects of
the ACA
Source: Kindig and Stoddart. “What is Population Health?” Am
J Public Health. 2003 March; 93(3): 380–383.
39

40. “Health in All Policies” Approach
– Increasing awareness that factors outside
of the health system affect health status
– Incorporates Social Determinant
perspective
– Policy Relevance
• Improved productivity
• Reduced health care costs (‘economic
security’)
40

41. Evidence-Generating Orgs

42. How to Act on what we Learn?
 Though we are
generating new
evidence, aligning
interests and
partnering with
stakeholders… how do
we translate,
disseminate, and
implement what we
know to improve care?

43. Agenda
 Overview of AcademyHealth
 How the U.S. Compares: Quality and
Outcomes
 Leading Approaches in Other Countries
 Burgeoning Field of Implementation Science

44. What is implementation science?
 Research relevant to the scientific
study of methods to promote the
uptake of research findings into
routine healthcare in both clinical
and policy contexts.
http://www.implementationscience.com/

45. What is in a name?
 Implementation science
 Improvement science
 Delivery system research
 Dissemination and implementation research
 Quality improvement research

46. Pipeline from research to practice to policy

47. The Translational Pathway
 Innovation
 Pilot testing
 Rigorous assessment
 Replication and spread
 Scale-up

48. Focus on Adoption, the “Triple S”
Scale up, Sustainability, Spread
 US
– AHRQ
– PCORI
– CMMI
– Million Hearts
– VA
– NIH – Dissemination and implementation
activities; NCATS/CTSA
 International

49. Focus on Adoption, the “Triple S”
Scale up, Sustainability, Spread
 Cochrane Effective Practice and Organisation
of Care (EPOC) Group
– Reviews of interventions designed to improve
professional practice and the delivery of effective
health services.
 Health evidence Canada
– Facilitate the adoption and implementation of
effective policies/programs/interventions at the
local and regional public health decision making
levels across Canada.

50. A New International Society on
Research on How to Improve Care
 An inclusive approach: mental health healthcare,
treatment for substance abuse, the work of allied
health professions, and preventive healthcare.
 Open to researchers from all traditions: rigorous
methods, focused on improving healthcare,
knowledge that can be transferred across settings.
 Improvement science, behavioral medicine,
knowledge translation
 Start international debate, shared vision, seek
funding opportunities and engage stakeholders.
 Now seeking comment online.

51. Outline
 Overview of AcademyHealth
 How the U.S. Compares: Quality and
Outcomes
 Leading Approaches in Other Countries
 Burgeoning Field of Implementation Science
 Concluding Thoughts

52. Future Challenges
 Ensuring rigorous methods match policy and practice
needs.
 Key requirements for creating comparable indicators
that address the needs of policy-makers are:
– appropriate methods of summarizing complex information;
– a narrative that picks out the key issues and uncertainties;
– a diagnosis of why the reported variations are arising; and
– an assessment of implications for policy action.
http://www.euro.who.int/en/what-we-do/data-and-evidence/health-
evidence-network-hen/publications/2012/health-system-
performance-comparison-an-agenda-for-policy,-information-and-
research-2012

53. Future Challenges (cont)
 Harmonize and coordinate federal efforts to
fund research
 Build a high performing comparative
effectiveness research system to achieve
rapid-learning potential of electronic health
records, databases, data sharing, networks
 Support a rapid-learning culture for the US
health care system
Etheredge, Lynn. “Creating a High-Performance System
for Comparative Effectiveness Research.” Health
Affairs. 29; No. 10 (2010): 1761-1767

54. Wither AcademyHealth?
 Continued focus on
– Evidence generation
– Evidence translation
 Engage & learn from international colleagues
– Update to 2009 report on CER efforts
– Delegation to Beijing to attend 2nd Global
Symposium on Health Systems Research
– Your thoughts?

55. Questions?
Lisa Simpson, MB, BCh, MPH, FAAP
President and CEO