Karen Davis, Ph.D., is the Eugene and Mildred Lipitz Professor in the Department of Health Policy and Management and director of the Roger C. Lipitz Center for Integrated Health Care at the Bloomberg School of Public Health at Johns Hopkins University. From 1995 to 2012, she was the president of the Commonwealth Fund, a national philanthropy engaged in independent research on health and social policy.

Davis is the 2013 recipient of the TRUST Award from the Health Research & Educational Trust, an AHA affiliate. She will receive the award July 25 in San Diego during the Health Forum-AHA Leadership Summit.

Maulik Joshi: What do you consider the Commonwealth Fund's most significant accomplishments during your tenure as president?

Karen Davis: I would underscore five things:

1. Contribution to health reform. When I think about what's been my passion throughout my professional life, it is seeing that people who need health care get it. The No. 1 thing that has prevented that has been gaps in insurance coverage. I once had a board member who said, "How long are we going to work on the uninsured?" And I said, "Until there are no more uninsured." Even when it wasn't possible to move it as an issue on the policy agenda, we continued to make people aware of the growth and the numbers of uninsured. We also focused attention on the underinsured — that it wasn't enough to have coverage. If you had high deductibles, you were virtually uninsured.

In 2000, we published an article in the Archives of Internal Medicine called "The 2020 Vision for American Health Care" that laid out an overall strategy combining both universal insurance coverage and payment delivery system reform. [Editor's note: See the table below for a summary of this and related publications.]

In 2003, we published a Health Affairs article called "Creating Consensus on Coverage Choices." It laid out the basic strategy of building on current sources of coverage. Democratic candidates running at that point in the [2004] primaries embraced that strategy. Later, it helped to shape the 2006 Massachusetts health reforms.

In November 2009, our Commission on a High Performance Health System put out a path report at the point when President Obama said to Congress, "You come up with a plan." They were looking around and said, "There's a plan." So it helped obviously. We were kick-off presenters at the House Ways and Means' first major hearing on health reform.

Key Commonwealth Fund Articles and Commission on a High-Performance Health System Reports


Year

Title

Content

2000

"A 2020 Vision for American Health Care" in Archives of Internal Medicine

Stresses the importance of universal coverage and access to patient-centered care, quality improvement and innovation

2003

"Creating Consensus on Coverage Choices" in Health Affairs

Describes a strategy of building on current sources of insurance coverage and setting up health insurance exchanges modeled on the Federal Employee Health Benefits Program

2007

Bending the Curve (commission report)

Examines the effects of 15 federal policy options; suggests strategies to reduce total health system expenditures without shifting them from the federal budget to state budgets, employers or households

2009

The Path to a High Performance U.S. Health System (commission report)

Develops an integrated plan that incorporates universal insurance coverage with projected savings of $3 trillion from 2010 to 2020

2013

Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System (commission report)

Recommends payment and other systemwide reforms and consumer incentives to control costs and improve health system performance, with savings of $2 trillion

2. Triple Aim. At the Commonwealth Fund, we did a lot of work on how to reform the delivery of care to achieve the triple objective of better access, improved quality and greater efficiency. We published articles and funded a lot of evaluations and some of the early efforts to provide payment incentives for patient-centered medical homes. So that delivery model, in particular, means a lot to me. We did similar work with a lower profile on resident-centered nursing home care. Again, the basic principle is quality of life, quality of care for patients or residents and reorganizing delivery to achieve that. We also did some of the first work on hospital readmissions; documenting that variability in hospital readmission rates was a major factor in Medicare variability and spending.

3. Annual international surveys. We started in 1998 with annual surveys of countries, with comparative data on health system performance. It changed the dial in thinking the United States has the best health care system in the world because it spends more than any other country. But we don't necessarily get more. The surveys pointed to innovation in other countries, including delivery of primary care, patient safety, information technology, and a whole host of comparative effectiveness research and innovations that provided learning opportunities for the United States.

4. Investing in future leaders. More than a hundred minority physicians have participated in the master's program at Harvard School of Public Health — now called the [James] Mongan Commonwealth Fund Fellowship Program in Minority Health Policy — as well as in our international Harkness Fellowships in Health Care Policy and Practice. We reoriented our international program, which the Commonwealth Fund had since 1925, and focused it on health care, and we focused the fellowships specifically on physicians, health administrators and health policymakers with a real potential for leadership. People in their 30s and 40s come to the United States for a year to be exposed to innovation and to foster collaborative research and learning across countries.

5. Effective communications. Hitting the modern communication era with the Internet enabled us to get information out quickly to those who could use it and help shape the debate on health policy. I am very proud of Why Not The Best? — wntb.org — that has performance data on hospitals. We found that hospitals are able to compare themselves against others and aspire to be among the top 10 percent. It was a real way of generating the will for change and helped to improve not only the policy debate, but also the delivery system.

Creating a High-Performance Health System

Joshi: What are some of the major recommendations from the Commission on a High Performance Health System?

Davis: The commission started in 2005 and had a charge of better access, improved quality and greater efficiency in health care, so win-win-win solutions. It issued a framework for a high-performance health system and five strategies for getting there: (1) access to care for all; (2) incentives aligned to reward the kind of change we'd like to see; (3) access to patient-centered, coordinated care; (4) quality improvement and innovation; and (5) public and private leaders working together toward shared goals.

We started the work of the commission with scorecards, first with a national report called "Why Not the Best?" in 2006, then the state scorecard called "Aiming Higher" in 2007, and a local scorecard, "Rising to the Challenge," in 2012. We were very nervous putting those together, thinking that people might focus on poor performers. But we kept saying that everybody should aim for the 90th percentile, and it came out with that effect. It took away "you can't do it" and replaced it with "why do they do it?" "how do they do it?" and "how do we get there?" Whether it was the state comparisons or geographic comparisons or individual provider comparisons, everybody got very focused on getting to the top, which I think mobilized change.

There were three major commission reports [see accompanying table]. The first, in 2007, called "Bending the Curve," was the first to popularize that phrase. The report had a series of recommendations and included specific cost estimates — "If you do all of these things, this is what will result." That report was followed in February 2009 with "The Path to a High Performance U.S. Health System;" "high performance health system" is used all the time now. In January 2013, the commission published another report, "Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System." The basic notion from the international work and the commission's work: It is possible to cover everybody and pay for it without busting the bank. But to do it, we need some fundamentally different ways of delivering and paying for services.

Advice for Health Care Leaders

Joshi: How can we better use research and evidence in the design that we are doing? How do we move this knowledge into practice?

Davis: I think the challenge for the research community right now is to inform implementation. It is one thing to inform the grand ideas and overall shape at the 30,000-foot level. But, pragmatically, what does a hospital do? What does a primary care practice do? What does a nursing home do? It needs a lot more information on what worked, who the top performers are and why. It needs case studies, best practices and peer-to-peer exchanges. It is easiest to learn from other people who have been in your shoes, done it and succeeded — with the obstacles you've had.

How do you do it? A little bit at a time. For hospitals, more and more of their revenue is going to be bundled or population-based. But right now, hospitals still see a lot of fee-for-service, and filling beds makes them profitable. It is not just what to do, but when to do it, the speed at which you do it and how big a bet you put on it in terms of the entire organization.

Joshi: What is your advice to leaders in terms of today's work toward value and how they should keep moving forward?

Davis: The challenge is to be ahead of the curve — to know what's coming. In the foundation world, we fund research that we think will answer questions that policy officials will have 18 to 24 months from now. For those in the delivery system, it is knowing where the puck is going and how to get their organization ready for the coming trends.

In general, never rest on laurels. It is easy in the health care world to be proud of what you've done, knowing you have built a great institution and are doing a great job. But it is never being satisfied. It is always finding, "Where are we weak? Where could we do better?" It is always keeping an eye on comparative performance and who's the very best at X, Y or Z and what can we learn from them — how we can mobilize and inspire everybody throughout the organization to work on each of those pieces to achieve that overall performance.

Maulik Joshi, Dr.P.H., is the president of HRET and senior vice president for research at the American Hospital Association. He is also a member of Speakers Express.