Improve the safety, quality, affordability, and accessibility of health care, including behavioral health care and long-term care.
Today, disease, illness, and disability can be as much a threat to Americans’ financial well-being as they are to Americans’ physical and mental well-being. Every American deserves reliable, high-quality, and reasonably priced health care that will be there when it is needed. Health care has to be available, affordable, portable, transparent, and efficient.
Health care in the United States is second to none, but it can be better. Although our Nation’s health care facilities and medical professionals are the best in the world, improving quality, constraining costs, and providing greater access remain key priorities.
Americans spend an increasing share of their income on health care. Health care spending in America has increased from 5 percent of Gross Domestic Product (GDP) in 1960 to more than 16 percent in 2006, and is predicted to continue to rise.iv The increasing burden of health spending on the U.S. economy is unsustainable. Higher spending on public programs such as Medicare and Medicaid strains Federal and State budgets. Higher insurance premiums burden workers with higher health costs and pose a challenge for employers to cover both wage increases and health insurance premiums.
The system needs to make progress in providing the excellent quality of care that all Americans deserve. We need to increase the rate at which patients receive recommended services and to reduce the number of unnecessary services. We also must eliminate preventable medical errors.
Forty-six million Americans do not have health insurance.v These individuals may face barriers to obtaining timely and continuous care. Because of their limited access to the system, their health problems may become more severe and further increase health care costs in the future.
One critical part of HHS’s strategy to address these problems is to improve transparency within the health care system. Because third parties such as insurance companies, employers, and governments finance the vast majority of health care spending, most Americans do not know—and do not have access to information about—the cost and quality of health care services in order to decide whether they want to receive those services.
Making health care affordable, accessible, and high quality depends on providing consumers with the knowledge they need to make informed choices about their health care coverage. The Federal Government must lead in accomplishing these objectives. We are encouraged that others in the private sector have joined in such efforts; we will continue to pursue these goals, which characterize a value-driven health care system.
The increasing costs of health care services, our increasingly older population with multiple chronic conditions, and an increasingly complex health care system challenge us to continue our efforts to develop new strategies to maintain safe and affordable services designed to meet Americans’ needs in their various income, family, and health circumstances. HHS is working to improve the efficiency and quality of health care that it finances and delivers. Promoting greater use of health information technology will ensure that accurate and timely information on a patient’s condition is available to all providers involved in the patient’s care and will reduce unnecessarily redundant diagnostic tests and office visits that add to health care costs. Implementation of value-based purchasing systems that include incentives to providers for treatment outcomes, rather than just reimbursements for treatments, will again help move the system toward more efficient and cost-effective provision of care aimed at improving the health and quality of life of the citizens touched by HHS programs.
At the same time, we must ensure that our efforts to reduce the cost of high-quality health care are reflected in more affordable and accessible health insurance coverage, to address the problem of the Nation’s growing number of citizens without health insurance. HHS continues to explore options for increasing the portability and accessibility of health insurance through innovative vehicles such as Health Savings Accounts coupled with high-deductible health plans, which have grown in popularity in recent years. Additionally, HHS is working to increase access to private health insurance for those who do not yet have it through initiatives such as Affordable Choices. Together, these initiatives will assist individuals in maintaining their health and prevent health spending from overburdening the economy.
Finally, the need to rebuild the health care infrastructure in New Orleans in the wake of Hurricane Katrina offers the Department and its State and local partners the challenge of coordinating coverage; system capacity; and workforce recruitment, retention, and development in new ways that result in a revitalized health care system for that community.
Strategic Goal 1, Health Care, targets the need for people to be able to obtain and maintain affordable health care coverage; receive efficient, high-quality health care services; and access appropriate information for informed choices. HHS’s Administration on Aging (AoA), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration (HRSA), and Indian Health Service (IHS) have significant roles to play in realizing this goal. In addition, the Food and Drug Administration (FDA), Office of the Assistant Secretary for Planning and Evaluation (ASPE), Office for Civil Rights (OCR), Office on Disability (OD), Office of Public Health and Science (OPHS), and Substance Abuse and Mental Health Services Administration (SAMHSA) play roles in addressing this goal.
There are four broad objectives under Health Care:
- Broaden health insurance and long-term care coverage;
- Increase health care service availability and accessibility;
- Improve health care quality, safety, cost, and value; and
- Recruit, develop, and retain a competent health care workforce.
Below is a description of each strategic objective, followed by a description of the key programs, services, and initiatives the Department is undertaking to accomplish those objectives. Key partners and collaborative efforts are included under each relevant objective. The performance indicators selected for this strategic goal also are presented with baselines and targets. These measures are organized by objective. Finally, this chapter discusses the major external factors that will influence HHS’s ability to achieve these objectives, and how the Department is working to mitigate those factors.
Strategic Objective 1.1: Broaden health insurance and long-term care coverage.
HHS is committed to broadening health insurance and long-term care coverage. The multifaceted approach to expanding consumer choices includes strengthening and expanding the safety net through programs such as Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP); creating new, affordable health insurance options; and creating new options for long-term care, including State Long-Term Care Partnership Programs. The operating and staff divisions contributing to the achievement of this objective include CMS, SAMHSA, AoA, HRSA, and OD.
The growing availability of prescription drugs and their cost have had a significant impact on health insurance. The first selected performance indicator, at the end of this chapter, measures the percentage of Medicare beneficiaries who have insurance coverage for prescription drugs through the Medicare drug benefit (Part D) or other coverage. This enrollment is expected to increase. Also, health care coverage for millions of present and future Medicare participants is protected by ensuring that the level of improper payments in the Medicare Fee-For-Service program remains low.
Strategic Objective 1.2: Increase health care service availability and accessibility.
In addition to broadening health care and long-term care coverage, HHS is committed to increasing the availability and accessibility of health care services. This commitment includes reaching out to vulnerable and underserved populations, such as American Indians and Alaska Natives, people with disabilities, and rural populations. In addition, the Department is committed to enhancing and expanding existing services, such as health centers, long-term care options, substance abuse and mental health treatment programs, and Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) programs. Among the operating and staff divisions contributing to the achievement of this objective are AoA, CMS, HRSA, IHS, OCR, OD, ONC, OPHS, and SAMHSA.
Selected HHS performance indicators that best capture the impact of the wide array of HHS services provided under this strategic objective follow:
- Key aspects of having regular access to a source of ongoing care for the entire population;
- Receipt of services by American Indians and Alaska Natives, with whom HHS has a special treaty relationship;
- Efforts to expand access to publicly funded health centers and substance abuse treatment programs; and
- Rates at which programs funded by Title XXVI of the Public Health Service Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act (Ryan White HIV/AIDS Program) serve racial and ethnic minorities, disproportionately affected by HIV/AIDS.
The joint planning initiative, Empower Consumer Access to Health Care, Long-Term Care, and Behavioral Health Services, is responsible for development, implementation, and coordination of health care, long-term care, and behavioral health service policies and programs. Ten HHS divisions partner with the U.S. Departments of Agriculture, Education, and Interior, as well as with State and local health departments, Medicaid and SCHIP State agencies, State and area agencies on aging, child care providers, early education providers, and tribal governments.
Strategic Objective 1.3: Improve health care quality, safety, cost, and value.
In the future, American health care will be shaped into a system in which doctors and hospitals succeed by providing the best value for their patients. Value in health care means delivering the right health care to the right person, at the right time, for the right price. Providing reliable health care cost and quality information can empower consumer choice at all levels. Systemwide improvements can occur as providers and payers can track how their practice, service, or plan compares to others. As value in health care becomes transparent to consumers and providers alike, HHS anticipates the following benefits: Costs will stabilize; more people will acquire insurance; more people will get access to better health care; and economic competitiveness will be preserved. Ultimately, this is a prescription for a value-driven system—a prescription of good medicine that works for everyone. HHS will work to achieve this value-based system over the next 5 years.
Several HHS operating and staff divisions contribute to this goal of improving the quality, safety, cost and, ultimately, the value of health care, including AHRQ, AoA, CMS, FDA, HRSA, IHS, NIH, ONC, OPHS, and SAMHSA.
The performance indicators for this strategic objective, listed in full at the end of this chapter, measure:
- Adoption of electronic health care records, which affect the long-term quality, value, and safety of health care;
- Quality of care that residents receive in nursing home facilities; and
- Number of States implementing specific approaches to improve the quality of Medicaid-funded health care, on which many low-income people depend.
Strategic Objective 1.4: Recruit, develop, and retain a competent health care workforce.
In the coming years, the Nation faces shortages of critical health care workers, including nurses and long-term care providers. In addition, all health care workers will need to be flexible and responsive enough to act on new challenges and maximize the potential of new technologies. In addition to strategies to develop its own workforce, HHS is committed to helping the field recruit and retain, as well as train, develop, and support, a competent professional and paraprofessional health care workforce. Among the operating and staff divisions contributing to the achievement of this objective are AoA, ASPE, CMS, HRSA, IHS, OPHS, and SAMHSA.
HHS, in the health care programs it operates, faces the same recruitment and retention challenges encountered by health care providers nationwide. The first performance indicator measures HHS’s success in meeting its goal to recruit and retain the Commissioned Corps members needed to provide ongoing health care. The second measures the Corps’ readiness to rapidly respond to medical emergencies and urgent public health needs.
Meeting External Challenges
HHS faces a number of challenges in improving the safety, quality, affordability, and accessibility of health care, including shifting demographics, changing trends in demand, increasing costs, and continuing concerns about implementing new technologies.
Demographic changes include the aging of the Nation’s population and increasing life expectancy, a growing number of persons with disabilities, and an increasing number of populations who do not speak English and have low literacy. HHS is working to meet the challenge by targeting its outreach materials and media responses to these populations, monitoring trends in access and availability of care for these populations, and continuing to design and implement innovative demonstration programs and initiatives aimed at reducing disparities. For more information about this topic, see Chapter 4’s In the Spotlight: Demographic Changes and Their Impact on Health and Well-Being.
With these demographic changes, changes in demand are expected to follow. Enhanced outreach to new populations means that HHS may need to think differently about responding to demands for high-quality, high-value, and accessible health care; behavioral health care; and long-term care. Surges in the Medicare-eligible population related to the aging of the Baby Boomers may strain the ability of the health care delivery system to respond appropriately. Even consumer perceptions about their need for preventive screenings or services impact overall demand. HHS is working to analyze background data from services provided to react to changing beneficiary needs. Evidence-based processes are being utilized to address coverage issues. Education campaigns are being conducted to raise awareness about beneficiary screening services and preventive care, with particular attention to growing racial and ethnic minority populations.
Although the above is true, one cannot assume that all costs are avoidable. Some of these costs substitute for the costs of excess mortality or morbidity. The United States continues to have the highest per capita health care spending among industrialized countries. The health care cost per capita for persons aged 65 years or older in the United States is three to five times greater than the cost for persons younger than 65, and the rapid growth in the number of older persons, coupled with continued advances in medical technology, is expected to create upward pressure on health care and long-term care spending. Medical inflation also contributes to the rising cost of providing appropriate quality health services, widening the gap between increased need and available resources. An economic downturn could increase demand for health care and long-term care services from safety net providers and strain the ability of current providers to meet the demand. In response to these concerns, HHS will continue to monitor trends in access to care among uninsured, underinsured, and low-income individuals, and to design and implement innovative demonstration programs that seek to improve health and access to care among these groups. HHS will identify new resources to meet increased demands, focusing on efficiency and effectiveness of health care service delivery. HHS will also continue to cultivate a strong focus on prevention and wellness services (see Strategic Goal 2, Objective 2.3, for more detail).
Improving health care and the health of the population through the adoption of health information technology (health IT) is clearly a priority for HHS (see In the Spotlight: Advancing the Development and Use of Health Information Technology). The nationwide implementation of an interoperable health IT infrastructure has the potential to lower costs, reduce medical errors, improve the quality of care, and provide patients and physicians with new ways to interact. However, nationwide health IT adoption can be accomplished only through a coordinated effort of many stakeholders, from State and Federal governments and the private sector. HHS has taken great care to engage representatives from all of these sectors in all of our health IT initiatives—an effort that involves many processes and the work of many hundreds of participants. In September 2005, HHS formed a Federal Advisory Committee (subject to the Federal Advisory Committee Act4 of 1972 (Public Law 92-463), as amended), the American Health Information Community (AHIC), to advise the Secretary on how to accelerate the development and adoption of health IT and help advance efforts needed to achieve the President’s goal for most Americans to have access to secure electronic health records by 2014. Additionally, the AHIC provides input and recommendations to HHS on how to make health records digital and interoperable and how to protect the privacy and security of those records, in a smooth, market-led way.
In the Spotlight: Reducing Health Disparities
The United States health care delivery system encompasses outstanding providers, facilities, and technology. Many Americans enjoy easy access to care. However, not all Americans have full access to high-quality health care.
The National Healthcare Disparities Report (2006 Disparities Report), published annually by the Agency for Healthcare Research and Quality (AHRQ), provides a comprehensive national overview of disparities in health care in America and tracks the Nation’s progress toward the elimination of health care disparities.xvi Measures of health care access are unique to this report and encompass two dimensions of access: facilitators and barriers to care, and health care utilization.
Three key themes are highlighted for those who seek information to improve health care services for all Americans:
- Disparities remain prevalent;
- Some disparities are diminishing, while others are increasing; and
- Opportunities for reducing disparities remain.
HHS is undertaking numerous initiatives aimed at reducing health care disparities and improving overall health care quality. These include, for example:
- Activities coordinated by OCR, OPHS, and the HHS Disparities Council;
- AHRQ’s “Asthma Care Quality Improvement: A Resource Guide for State Action”;
- AHRQ’s “Diabetes Care Quality Improvement: A Resource Guide for State Action,” which provides background information on why States should consider diabetes as a priority for State action, presents analysis of State and national data and measures of diabetes quality and disparities, and gives guidance for developing a State quality improvement plan;
- AHRQ’s “State snapshots” of data, which are made available to State officials and their public sector and private sector partners to understand health care disparities;
- AHRQ’s national health plan learning collaborative to reduce disparities and improve diabetes care;
- CDC’s National Breast and Cervical Cancer Early Detection Program;
- CMS’s Hospital, Nursing Home, Home Health, and End Stage Renal Disease Quality Initiatives;
- HRSA’s C.W. Bill Young Cell Transplantation Program and National Cord Blood Inventory to increase access to sources of high-quality blood stem cells for transplantation for patients without a suitable related blood stem cell donor;
- HRSA’s Health Disparities Collaborative Initiative, which seeks to generate and document improved health outcomes for underserved populations;
- HRSA’s Healthy Start program, which works in 97 communities with high annual rates of infant mortality to reduce disparities and improve health outcomes for mothers and infants from pregnancy to at least 2 years after delivery;
- HRSA’s Maternal and Child Health Block Grant, aimed at improving care for all mothers and children; and
- HRSA’s Organ Donation Collaborative, aimed at increasing the number of organ donations and transplants.
In the Spotlight: Advancing the Development and Use of Health Information Technology
[Inset box: Health information technology is defined as systems and products that electronically create, store, transmit, and present personal health information for multiple purposes, most notably for patient care.]
The Institute of Medicine estimates that 44,000 to 98,000 Americans die each year from medical errors. Many more die or have permanent disability because of inappropriate treatments, mistreatments, or missed treatments in ambulatory settings. Predictive models have projected that as much as $300 billion is spent each year on health care that is the result of our fragmented, uninformed, and uncoordinated health care system. According to the National Coalition on Health Care, in 2004 health care spending in the United States reached $1.9 trillion and was projected to reach $2.9 trillion in 2009, if the current system does not change. In order for health care in the United States to be safe, timely, effective, efficient, equitable, and patient centered, three elements will be necessary:
- All relevant information (about a patient, the latest scientific evidence, and environmental factors) must be available electronically at the time of patient care;
- Patients must be informed and engaged in their own health; and
- Care must be considered, assessed, and coordinated across multiple sites and settings.
Clearly, health IT is the critical tool that can significantly reduce medical error, engage consumers and patients in their own health and care, and provide information in a coordinated fashion. In addition, public health and bioterrorism surveillance can be seamlessly integrated into care, and clinical research will be accelerated and postmarketing surveillance expanded. Interoperable health IT is the key to transforming our health care system.