Pay for Performance and the Healthcare Value Paradigm

Debra A. Harrison

Chapter 12

“Price is what you pay. Value is what you get.”

—Warren Buffett

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

—Johann Wolfgang von Goethe

Learning Objectives

Analyze and discuss the evolution of quality in healthcare.

Discuss a range of approaches to the implementation of a total quality program in a healthcare organization, including Donabedian’s model of structure, process, and outcomes.

Articulate the concept of value and discuss performance measures that are important in healthcare organizations.

Define pay for performance and discuss some of the current initiatives in healthcare reimbursement.

Demonstrate the ability to link quality, efficiency, and financial decision making in an organization’s strategic plan.

Key Terms and Concepts

Donabedian framework

Leapfrog Group

Nurse-sensitive patient outcomes

Pay-for-performance (P4P) programs

Quality

Therapeutic alliance

Value

Value-based purchasing

Value frontier

Introduction

A paradigm shift from the efficiency frontier to a value frontier is occurring in healthcare.

The value frontier is a benchmark that takes into account not only efficiency but also quality.

A healthcare organization is efficient if it has achieved an optimal fit between its structural characteristics and its processes.

However, the healthcare environment is dynamic and requires organizations to make changes on a continuous basis.

The Cost of Quality

US healthcare spending grew 3.6 percent in 2013, reaching $2.9 trillion, or $9,255 per person (CMS 2014c).

How to provide access to affordable healthcare is an ongoing philosophical discussion in modern medicine.

In healthy industries, competition is not based on cost but on value, which is the level of consumer benefit received per dollar spent.

To encourage quality improvement and more efficient delivery of healthcare services, the government, insurance companies, and other groups implement pay-for-performance (P4P) programs.

(V) = Q/C

Value (V): Level of consumer benefit received per dollar spent.

Q: Quality

C: Cost

Commonwealth Fund

The Commonwealth Fund is a private institution whose goal is to improve access to care, quality of care, and efficiency of care in the United States.

Reports from their studies in 2011 estimate that healthcare waste and medical errors account for $100 billion of US healthcare expenses and may cost 150,000 lives annually.

For more statistics and facts, visit:

www.commonwealthfund.org/

Change in Rates for Hospital-Acquired Conditions, 2010–13

Source: Agency for Healthcare Research and Quality, Efforts to Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013, Dec. 2014.

Column1
Adverse Drug Events Catheter-Associated UTIs Central Line-Associated Bloodstream Infections Falls Pressure Ulcers Surgical Site Infections Ventilator-Associated Pneumonias Venous Thromboembolisms Total -0.19 -0.28000000000000003 -0.49 -0.08 -0.2 -0.19 -0.03 -0.18 -0.17

GDP refers to gross domestic product.

Source: OECD Health Data 2014.

Healthcare Spending as a Percentage of GDP, 1980–2012

Percent

2011.

At the same time, our quality is not higher than other countries spending less.

Medicare Pay-for-Performance Initiatives

Title III of the ACA mandated a financial reward to improve quality, safety, and the patient experience for Medicare patients, an initiative called value-based purchasing (VBP).

Began in 2013 with reimbursements for patient discharges on or after October 1, 2012. CMS automatically withholds a hospital’s Medicare payments by a specified percentage each year (see chart), and hospitals can earn back that percentage if they achieve certain quality and patient satisfaction scores

The intent of the law is that the program be budget neutral, meaning that organizations performing in the bottom 10 percent lose the Medicare payment reduction and the top 10 percent receive the Medicare payment incentive.

Medicare Pay-for-Performance Initiatives

CMS measures of efficiency now include a cost metric. This metric is called the Medicare Spending per Beneficiary (MSPB) and is defined as the average Medicare Part A and B spending per patient from 3 days prior to admission to 30 days after discharge (Chen and Ackerly 2014).

VBP also means efficient care, which will require physicians to limit the number of tests they order that do not improve morbidity or mortality.

The basis of CMS’s recent P4P initiatives is a collaboration with providers to ensure that valid measures are used to achieve improved quality.

CMS has explored P4P initiatives in nursing home care, home health care, dialysis, and coordination of care for patients with chronic illnesses.

Exhibit 12.2: Hospital Value-Based Purchasing Program Measures, 2016

Additional Initiatives in Pay For Performance

Commercial Payer Initiatives

CMS is not the only entity offering P4P incentives. US health plans and other payers are also developing P4P programs to improve the quality of care and minimize future cost increases.

In 2009, more than 250 private P4P programs existed across the nation, half of those programs targeting hospital care (Cauchi, King, and Yondorf 2010).

The California Pay for Performance Program is the largest and longest-running private sector P4P program.

It was founded in 2001 as a physician incentive program and has focused on measures related to improving quality performance by physician groups.

Additional Initiatives in Pay for Performance

Leapfrog Group

The Leapfrog Group is a purchaser that represents many of the nation’s largest corporations and public agencies that buy health benefits on behalf of their enrollees.

Their mission is to use employer purchasing power to improve the quality, efficiency, and affordability of US healthcare.

Leapfrog represents both the private and the public sector as well as more than 34 million Americans and tens of billions in healthcare expenditure (Leapfrog 2015a).

Additional Initiatives in Pay for Performance

Leapfrog Group (cont.)

Leapfrog’s hospital reporting initiative assesses hospital performance on the basis of quality and safety measures developed by the National Quality Forum (NQF).

Leapfrog is focused on four major “leaps” to make healthcare safer: computerized physician order entry, evidence-based hospital referral, intensive care units staffed with physician specialists, and hospitals’ progress on eight NQF benchmarks (called Safe Practices).

www.leapfroggroup.org/

Physician’s Attitudes Regarding Pay for Performance

Lee, Lee, and Jo (2012) did a systematic review of provider attitudes and P4P. Their findings:

Healthcare providers still have a low level of awareness about P4P.

Providers are concerned that P4P may have unintended consequences.

They believe additional resources will be needed to provide adequate quality indicators and implementation of P4P.

To counteract the attitudes, healthcare organizations should:

Develop more accurate quality measures to minimize any unintended consequences.

Emphasize provider education.

Emphasize technical support to reduce provider burden.

Incorporating Pay for Performance into a Strategic Plan

Current and past P4P initiatives have focused on improving quality and reducing costs—two key factors in gaining a competitive advantage.

Strategic planners should routinely monitor their CMS Hospital Compare quality scores to raise them to the level of CMS’s P4P incentives.

If their scores are already at that level, they should focus on driving them up further to maximize rewards and reimbursement; the higher the quality, the greater the reward.

Planners need to allocate money to invest in programs and new technology that will help the hospital increase its quality scores.

In areas where quality is poor and unlikely to change, the strategic planner should consider closing the service so that patient safety is not jeopardized and the hospital is less likely to incur malpractice suits.

Donabedian and Quality

Avedis Donabedian (1966), considered the father of quality assurance in healthcare, defined quality as a reflection of the goals and values currently adhered to in the medical care system and the society in which it exists.

The Donabedian framework is a model for evaluating the quality of medical care based on three criteria:

Structure

Includes the environment in which healthcare is delivered

The instruments and equipment providers use

Administrative processes and qualifications of the medical staff

The fiscal organization of the institution

Process

How care is delivered

Outcomes

Recovery

Restoration of function

Survival

Are We Achieving What We Hoped with VBP?

Spaulding, Zhao, and Haley (2014) reported that, while the VBP measures are covering process, structure, and outcomes, they do not correlate with an improvement in hospital-acquired conditions.

This result could mean that we are not measuring the correct processes, or that the outcome measurements do not reflect the quality we are trying to achieve.

Future healthcare leaders must answer this interesting question:

Which is more important—promoting an incentive system that lacks a clear indication of the outcomes that health systems should be measuring, or changing the process measures to ensure that the outcomes organizations care about are actually being measured?

Defining Quality

No single definition of healthcare quality exists, nor is there a single method of measuring quality in healthcare.

Access to healthcare for all Americans is paramount in the quality literature.

The ACA was more about access and insurance reform than healthcare reform.

The consumer’s ability to choose a physician or care setting is another focal point.

The rise of health maintenance organizations (HMOs) in the 1990s, with their limited network plans, left some consumers worried about choice.

The ACA insurance exchange program gives consumers choices along a range of plans, including the bronze, with a narrow network and lower premiums, and the platinum plan, with a broader network and higher premiums.

Comparative Outcomes

Dr. Ernest Codman researched healthcare quality by measuring quality outcomes. His end results theory advocated measuring patient care to assess hospital efficiency and to identify clinical errors or problems.

On the basis of this theory, the college created the Hospital Standardization Program, which later evolved into The Joint Commission on Accreditation of Healthcare Organizations (now simply “The Joint Commission”).

The initial purpose of measuring the quality of healthcare outcomes and processes was to help patients make informed healthcare decisions.

Research shows that Americans rate quality as the most important factor when choosing a health plan. Studies also show that most do not understand their options well enough to make an informed choice.

Public and private groups, such as the National Committee for Quality Assurance (NCQA), have developed tools for measuring and reporting healthcare quality.

Quality Metrics

Growing Demand for Quality-Related Data

Demand for quantitative data on healthcare quality is growing.

Quality measures should be based on peer-reviewed national standards of care.

Employers often find it difficult to determine what hospital quality measures are important, how to interpret and use quality information in a meaningful way, and how to present useful information to consumers (Carrier and Cross 2013).

The demand for data has pushed the implementation of electronic health records (EHRs), and meaningful use initiatives have furthered that effort.

To minimize the burden on clinicians, a combination of clinical knowledge and technological expertise is required to implement manually intensive steps so that hospitals can begin to use EHR-specific quality measures (Amster et al. 2014).

Quality Metrics

Growing Demand for Quality-Related Data

Hospital Compare allows the public to select up to three hospitals to compare quality measures related to heart attack, heart failure, pneumonia, surgery, and other conditions. These measures are organized by the following:

Patient survey results (HCAHPS)

Timely and effective care

Readmissions, complications, and deaths

Use of medical imaging

Linking quality to payment

Medicare volume

www.medicare.gov/hospitalcompare/search.html

Quality Metrics

Agency for Healthcare Research and Quality

AHRQ—whose mission is to produce evidence that helps make healthcare safer and higher quality, as well as more accessible, equitable, and affordable—is a division of the US Department of Health and Human Services (HHS).

AHRQ collects data on the following:

Inpatient mortality for certain procedures and medical conditions

Utilization of procedures for which there are questions of overuse, underuse, and misuse

Volume of procedures (some evidence suggests that a higher volume of procedures is associated with lower mortality)

For more information, go to http://www.ahrq.gov/research/data/state-snapshots/index.html

Quality Metrics

Patient Safety

The Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System, published in 1999, described the problems surrounding patient safety.

The report listed six aims designed to improve safety. Healthcare must be:

Safe

Effective

Patient- centered

Timely

Efficient

Equitable

The Joint Commission publishes National Patient Safety Goals that it expects hospitals to address when pursuing accreditation. www.jointcommission.org/assets/1/6/2015_hap_npsg_er.pdf

Other Quality Considerations

Workforce

An unintended consequence of an emphasis on quality is a rise in the cost of nursing services and ancillary staff.

Studies have shown that patient outcomes are influenced by patient-to-nurse ratios (Spaulding, Zhao, and Haley 2014).

Hospitals with poor nurse staffing (more than four patients per nurse) have higher rates of risk-adjusted 30-day mortality and failure to rescue in surgical patients (Wiltse Nicely, Sloane, and Aiken 2012).

Healthcare organizations require a well-designed infrastructure for supporting nurses and other staff to maximize quality outcomes.

Research on workforce issues can help organizations determine the number of staff members, mix of expertise, and level of experience necessary to providing optimal care.

Other Quality Considerations

Magnet Recognition

The American Nurses Credentialing Center (ANCC) is the sponsor of the Magnet Recognition Program, which recognizes healthcare organizations for quality patient care, nursing excellence, and innovations in professional nursing practice.

Studies have shown that organizations that pursue or achieve Magnet recognition have improved patient outcomes, patient satisfaction, and nurse satisfaction.

Organizations may consider achieving Magnet status to be a strategic goal in improving nurse-sensitive patient outcomes—patient outcomes that improve if there is a greater quantity or better quality of nursing care (e.g., pressure ulcers, falls, intravenous infiltrations).

Other Quality Considerations

Patient Engagement

Research suggests that empowering patients to actively process information, to decide how that information personally affects them, and then to act on those decisions is a key driver behind healthcare improvement and cost reduction (Hibbard, Greene, and Overton 2013).

A therapeutic alliance is a partnership between patient and providers that involves collaboration and negotiation to arrive at mutual goals.

Employee Satisfaction

Efforts to create higher employee satisfaction have very desirable outcomes for patients, including increased patient satisfaction, improved care quality, and increased patient loyalty.

Other Quality Considerations

Accreditation

Healthcare quality is also maintained through accreditation, which is a standardized method of ensuring that quality processes are consistent throughout healthcare.

For instance, the American Society of Clinical Pathology accredits laboratory systems on the basis of the Clinical Laboratory Improvement Amendments passed by Congress in 1988, and the American College of Surgeons accredits trauma centers.

Balanced Scorecards

Most organizations have established a dashboard or scorecard that reflects current quality measures along with financial performance.

Balancing the two (hence the balanced scorecard) can improve the value frontier of the organization.

Strategic Planning for Healthcare Value

Patients, employers, and the government want high-quality, low-cost healthcare. The degree to which organizations successfully coordinate high quality with low cost reflects the value of the care they are delivering.

While planning for healthcare value, strategists must consider all of the topics presented in this book:

Development of a mission, vision, and culture that support change

A transformational approach to leadership

Evaluation of strengths, weaknesses, opportunities, and threats (SWOT analysis)

The use of health information technology

Examination of financial data

Healthcare marketing

Opportunities in accountable care organizations

Opportunities for joint venture, merger, and affiliation (with physicians and other organizations)

Compliance with P4P initiatives

Summary

Federal healthcare policymakers and state regulators have concerns about the negative impact that reduced reimbursement for healthcare services, low hospital occupancy, and poor efficiency can have on the quality of healthcare.

They also recognize that the aging population, the ACA-induced increase in the number of insured patients, and investments in healthcare technology will continue to drive up healthcare costs.

By operating in a manner consistent with evolving healthcare policy and the quality standards set forth by value-based purchasing programs, hospitals can receive financial and other rewards (e.g., a reputation for excellence), all of which will place them in a stronger competitive position.

Questions

References

Agency for Healthcare Research and Quality (AHRQ). 2015. Inpatient Quality Indicators: A Tool to Help Assess the Quality of Care to Adults in the Hospital. Accessed October 11. www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V42/Inpatient_Broch_10_ Update.pdf.

AHC Media. 2014. “Look Ahead to Succeed Under VBP.” Hospital Case Management. Published July 1. www.ahcmedia.com/articles/117227-look-ahead-to-succeed-under-vbp.

Aiken, L. H., S. P. Clarke, D. M. Sloane, J. Sochalski, and J. H. Silber. 2002. “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction.” Journal of the American Medical Association 288 (16): 1987–93.

American Nurses Credentialing Center (ANCC). 2015. “Magnet Model.” Accessed September 22. www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-Model.

Amster, A., J. Jentzsch, H. Pasupuleti, and K. G. Subramanian. 2014. “Completeness, Accuracy, and Computability of National Quality Forum-Specified eMeasures.” Journal of the American Medical Informatics Association 22 (2): 1–6.

Blumenthal, D., and K. Stremikis. 2013. “Getting Real About Health Care Value.” Harvard Business Review. Published September 17. https://hbr.org/2013/09/getting-real-about-health-care-value.

Carrier, E., and D. Cross. 2013. Hospital Quality Reporting: Separating the Signal from the Noise. National Institute for Health Care Reform. Published April. www.nihcr.org/ Hospital-Quality-Reporting.

Casalino, L. P., G. C. Alexander, L. Jin, and R. T. Konetzka. 2007. “General Internists’ Views on Pay-for-Performance and Public Reporting of Quality Scores: A National Survey.” Health Affairs 26 (2): 492–99.

References

Cauchi, R., M. King, and B. Yondorf. 2010. “Performance-Based Health Care Provider Payments.” National Conference of State Legislatures brief. Published May. www.ncsl.org/ portals/1/documents/health/perbenchformance-based_pay-2010.pdf.

Centers for Disease Control and Prevention (CDC). 2015. “Chronic Disease Prevention and Health Promotion.” Updated October 6. www.cdc.gov/chronicdisease/.

Centers for Medicare & Medicaid Services (CMS). 2014a. “Acute Inpatient PPS.” Modified August 4. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.

———. 2014b. “Medicare Program . . . .” Federal Register 79 (163): 49853–50536.

———. 2014c. “National Health Expenditures 2013 Highlights.” Accessed September 30. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ NationalHealthExpendData/Downloads/highlights.pdf.

Chen, C., and D. Ackerly. 2014. “Beyond ACOs and Bundled Payments: Medicare’s Shift Toward Accountability in Fee-for-Service.” Journal of the American Medical Association 311 (7): 673–74.

Donabedian, A. 1966. “Evaluating the Quality of Medical Care.” Milbank Quarterly 44 (3): 166–206.

Eisenberg, F., C. Lasome, A. Advani, R. Martins, P. A. Craig, and S. Sprenger. 2014. “A Study of the Impact of Meaningful Use Clinical Quality Measures.” Accessed September 29. www.aha.org/content/13/13ehrchallenges-report.pdf.

References

Emanuel, E. 2014. “In Health Care, Choice Is Overrated.” New York Times. Published March 5. www.nytimes.com/2014/03/06/opinion/in-health-care-choice-is-overrated.html.

Harrison, D., and C. Ledbetter. 2014. “Nurse Residency Programs: Outcome Comparisons to Best Practices.” Journal for Nurses in Professional Development 30 (2): 76–82.

Hibbard, J. H., J. Greene, and V. Overton. 2013. “Patients with Lower Activation Associated with Higher Costs; Delivery Systems Should Know Their Patients’ ‘Scores.’” Health Affairs 32 (2): 216–22.

Institute of Medicine (IOM). 1999. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press.

James, J. 2012. “Health Policy Brief: Pay-for-Performance.” Health Affairs. Published October 11. www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78.

The Joint Commission. 2014. “National Patient Safety Goals Effective January 1, 2015.” Published November 14. www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf.

Kronick, R. 2015. “AHRQ: Making Health Care Safer and Higher Quality for Every American.” AHRQ Views (blog). Agency for Healthcare Research and Quality. Published October 2. www.ahrq.gov/news/blog/ahrqviews/100215.html.

Leapfrog Group. 2015a. “Explanation of Safety Score Grades.” Published April. www.hospitalsafetyscore.org/media/file/ExplanationofSafetyScoreGrades_April2015.pdf

Leapfrog. 2015b. “The Leapfrog Group Fact Sheet.” Revised April 1. www.leapfroggroup. org/about_leapfrog/leapfrog-factsheet.

References

Lee, J. Y., S. Lee, and M. Jo. 2012. “Lessons from Healthcare Providers’ Attitudes Toward Pay-for-Performance: What Should Purchasers Consider in Designing and Implementing a Successful Program?” Journal of Preventive Medicine and Public Health 45 (3): 137–47.

National Committee for Quality Assurance (NCQA). 2014. “HEDIS and Performance Measurement.” Accessed September 30. www.ncqa.org/HEDISQualityMeasurement.aspx.

Piper, L. E. 2013. “The Affordable Care Act: The Ethical Call for Value-Based Leadership to Transform Quality.” The Health Care Manager 32 (3): 227–32.

Spaulding, A., M. Zhao, and D. R. Haley. 2014. “Value-Based Purchasing and Hospital Acquired Conditions: Are We Seeing Improvement?” Health Policy 118 (3): 413–21.

Tozzi, J. 2015. “U.S. Health-Care Spending Is on the Rise Again.” Bloomberg Business. Published February 18. www.bloomberg.com/news/articles/2015-02-18/u-s-health-care-spending-is-on-the-rise-again.

Trivedi, A. N., W. Nsa, L. Hausmann, J. S. Lee, A. Ma, D. W. Bratzler, M. K. Mor, K. Baus, F. Larbi, and M. J. Fine. 2014. “Quality and Equity of Care in U. S. Hospitals.” New England Journal of Medicine 371 (24): 2298–308.

Wiltse Nicely, K. L., D. M. Sloane, and L. H. Aiken. 2012. “Lower Mortality for Abdominal Aortic Aneurysm Repair in High-Volume Hospitals Is Contingent upon Nurse Staffing.” Health Services Research 48 (3): 972–91.

Chart1
8.746 7.4212 7.0316 7.2224 8.423 8.9494 6.9084 6.3528 5.7896 8.7312 6.9543 5.5831 6.1494
9.064 7.5079 1981 7.2874 8.7037 9.1534 7.1021 6.4228 5.7155 8.8703 6.6841 5.869 6.0846
9.8258 7.8094 1982 7.4365 8.5785 9.1599 7.8839 6.5818 5.8698 8.9822 6.8029 5.7202 6.343
9.9624 7.6702 1983 7.8328 8.5542 8.8835 8.0416 6.6848 5.7132 8.8897 6.9968 5.9302 6.3235
9.8722 7.3731 1984 7.5715 8.632 8.4606 7.9398 6.4848 5.4257 8.6829 6.6631 5.8561 6.3403
10.0372 7.3049 7.9957 7.5748 8.7774 8.4848 7.9583 6.5483 4.9871 8.369 6.5632 5.766 6.4416
10.1935 7.4334 1986 7.7627 8.671 8.1562 8.2126 6.5009 5.0841 8.1374 7.0414 5.7749 6.6478
10.4532 7.5755 1987 7.9847 8.7727 8.4641 8.142 6.5106 5.6169 8.1718 7.5276 5.8619 6.4726
10.8682 7.627 1988 8.0372 8.9432 8.6157 8.0947 6.2189 6.1815 8.0759 7.7183 5.7865 6.4041
11.2365 7.9176 1989 8.0633 8.3422 8.4518 8.3098 5.9696 6.3284 8.1093 7.5467 5.8206 6.4673
11.9005 8.0136 8.3666 7.9977 8.2875 8.344 8.7284 5.8107 6.73 8.1123 7.6381 5.8456 6.8241
12.5965 8.1651 8.6079 8.6524 1991 8.2229 9.4027 5.8521 7.1693 7.9583 7.9974 6.2547 7.0998
12.8885 8.3562 8.8661 9.0543 9.6248 8.2781 9.6557 6.1125 7.2982 8.1179 8.0893 6.7041 7.2014
13.1568 8.4743 9.2884 9.1374 9.6119 8.646 9.5252 6.3878 6.9919 8.4331 7.9431 6.7074 7.2405
13.0656 8.3296 9.2598 9.2183 9.818 8.4357 9.1843 6.6608 6.9953 8.0257 7.8503 6.7661 7.2353
13.1624 8.3273 10.3559 9.3343 10.1137 8.1253 8.8613 6.8069 7.0011 7.9646 7.8777 6.6942 7.2567
13.136 8.2115 10.3753 9.7152 10.4202 8.2115 8.6367 6.9536 6.9476 8.2003 7.8272 6.7214 7.4398
13.045 7.9493 10.2503 9.6698 10.2668 8.1509 8.6041 6.8907 7.1633 8.0264 8.3994 6.4838 7.4955
13.0643 8.0618 10.146 9.8465 10.2941 8.1561 8.8274 7.1766 7.5926 8.1154 9.252 6.555 7.6592
13.0677 8.0882 10.1536 10.0029 10.362 8.9536 8.7299 7.4407 7.472 8.1976 9.3286 6.8179 7.7856
13.1366 7.9579 10.0848 9.9081 10.3952 8.6991 8.6686 7.6034 7.5578 8.1796 8.4213 6.9327 8.0679
13.7863 8.2974 10.2113 10.2817 10.5042 9.1002 9.0959 7.8061 7.6596 8.8595 8.8014 7.2263 8.1747
14.6258 8.8699 10.5603 10.6066 10.7243 9.3329 9.37 7.8575 7.9731 9.2282 9.7911 7.5441 8.3866
15.1418 9.7728 10.7536 10.9339 10.9191 9.5094 9.5403 7.9881 7.7933 9.31 10.0222 7.7736 8.3145
15.2092 9.9683 10.8859 10.9612 10.6689 9.6749 9.5559 7.9947 7.9715 9.088 9.5982 7.9114 8.5703
15.2348 10.882 10.9326 10.8629 10.8088 9.77 9.5726 8.1819 8.3411 9.0615 9.0304 8.1287 8.451
15.336 10.7468 10.8522 10.3877 10.6373 9.9243 9.7174 8.1986 8.7432 8.948 8.564 8.2879 8.4871
15.6108 10.7642 10.7751 10.2099 10.477 9.9873 9.7938 8.2295 8.4458 8.9172 8.746 8.3717 8.5268
16.0842 10.9909 10.9124 10.289 10.7041 10.183 9.9886 8.605 9.2546 9.2284 8.5513 8.7826 8.7207
17.0543 11.8823 11.5992 11.0005 11.7539 11.4722 11.1226 9.5258 9.8354 9.939 9.6743 9.7298 9.0143
17.047 12.1468 11.5543 10.913 11.5567 11.0818 11.1128 9.589 9.952 9.4688 9.4224 9.3739 8.9303
17.0152 12.0956 11.5235 11.054 11.2489 10.8655 10.9398 10.0764 10.0009 9.4911 9.2834 9.2302 9.0791
16.8995 2012 11.6108 11.4304 11.2675 10.9838 10.9285 10.2804 2012 9.5788 9.2836 9.2716 2012
US (16.9%)
NETH (12.1%)*
FR (11.6%)
SWIZ (11.4%)
GER (11.3%)
DEN (11.0%)
CAN (10.9%)
JPN (10.3%)
NZ (10.0%)*
SWE (9.6%)
NOR (9.3%)
UK (9.3%)
AUS (9.1%)*
Sheet1
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
US (16.9%) 8.746 9.064 9.8258 9.9624 9.8722 10.0372 10.1935 10.4532 10.8682 11.2365 11.9005 12.5965 12.8885 13.1568 13.0656 13.1624 13.136 13.045 13.0643 13.0677 13.1366 13.7863 14.6258 15.1418 15.2092 15.2348 15.336 15.6108 16.0842 17.0543 17.047 17.0152 16.8995
NETH (12.1%)* 7.4212 7.5079 7.8094 7.6702 7.3731 7.3049 7.4334 7.5755 7.627 7.9176 8.0136 8.1651 8.3562 8.4743 8.3296 8.3273 8.2115 7.9493 8.0618 8.0882 7.9579 8.2974 8.8699 9.7728 9.9683 10.882 10.7468 10.7642 10.9909 11.8823 12.1468 12.0956
FR (11.6%) 7.0316 7.9957 8.3666 8.6079 8.8661 9.2884 9.2598 10.3559 10.3753 10.2503 10.146 10.1536 10.0848 10.2113 10.5603 10.7536 10.8859 10.9326 10.8522 10.7751 10.9124 11.5992 11.5543 11.5235 11.6108
SWIZ (11.4%) 7.2224 7.2874 7.4365 7.8328 7.5715 7.5748 7.7627 7.9847 8.0372 8.0633 7.9977 8.6524 9.0543 9.1374 9.2183 9.3343 9.7152 9.6698 9.8465 10.0029 9.9081 10.2817 10.6066 10.9339 10.9612 10.8629 10.3877 10.2099 10.289 11.0005 10.913 11.054 11.4304
GER (11.3%) 8.423 8.7037 8.5785 8.5542 8.632 8.7774 8.671 8.7727 8.9432 8.3422 8.2875 9.6248 9.6119 9.818 10.1137 10.4202 10.2668 10.2941 10.362 10.3952 10.5042 10.7243 10.9191 10.6689 10.8088 10.6373 10.477 10.7041 11.7539 11.5567 11.2489 11.2675
DEN (11.0%) 8.9494 9.1534 9.1599 8.8835 8.4606 8.4848 8.1562 8.4641 8.6157 8.4518 8.344 8.2229 8.2781 8.646 8.4357 8.1253 8.2115 8.1509 8.1561 8.9536 8.6991 9.1002 9.3329 9.5094 9.6749 9.77 9.9243 9.9873 10.183 11.4722 11.0818 10.8655 10.9838
CAN (10.9%) 6.9084 7.1021 7.8839 8.0416 7.9398 7.9583 8.2126 8.142 8.0947 8.3098 8.7284 9.4027 9.6557 9.5252 9.1843 8.8613 8.6367 8.6041 8.8274 8.7299 8.6686 9.0959 9.37 9.5403 9.5559 9.5726 9.7174 9.7938 9.9886 11.1226 11.1128 10.9398 10.9285
JPN (10.3%) 6.3528 6.4228 6.5818 6.6848 6.4848 6.5483 6.5009 6.5106 6.2189 5.9696 5.8107 5.8521 6.1125 6.3878 6.6608 6.8069 6.9536 6.8907 7.1766 7.4407 7.6034 7.8061 7.8575 7.9881 7.9947 8.1819 8.1986 8.2295 8.605 9.5258 9.589 10.0764 10.2804
NZ (10.0%)* 5.7896 5.7155 5.8698 5.7132 5.4257 4.9871 5.0841 5.6169 6.1815 6.3284 6.73 7.1693 7.2982 6.9919 6.9953 7.0011 6.9476 7.1633 7.5926 7.472 7.5578 7.6596 7.9731 7.7933 7.9715 8.3411 8.7432 8.4458 9.2546 9.8354 9.952 10.0009
SWE (9.6%) 8.7312 8.8703 8.9822 8.8897 8.6829 8.369 8.1374 8.1718 8.0759 8.1093 8.1123 7.9583 8.1179 8.4331 8.0257 7.9646 8.2003 8.0264 8.1154 8.1976 8.1796 8.8595 9.2282 9.31 9.088 9.0615 8.948 8.9172 9.2284 9.939 9.4688 9.4911 9.5788
NOR (9.3%) 6.9543 6.6841 6.8029 6.9968 6.6631 6.5632 7.0414 7.5276 7.7183 7.5467 7.6381 7.9974 8.0893 7.9431 7.8503 7.8777 7.8272 8.3994 9.252 9.3286 8.4213 8.8014 9.7911 10.0222 9.5982 9.0304 8.564 8.746 8.5513 9.6743 9.4224 9.2834 9.2836
UK (9.3%) 5.5831 5.869 5.7202 5.9302 5.8561 5.766 5.7749 5.8619 5.7865 5.8206 5.8456 6.2547 6.7041 6.7074 6.7661 6.6942 6.7214 6.4838 6.555 6.8179 6.9327 7.2263 7.5441 7.7736 7.9114 8.1287 8.2879 8.3717 8.7826 9.7298 9.3739 9.2302 9.2716
AUS (9.1%)* 6.1494 6.0846 6.343 6.3235 6.3403 6.4416 6.6478 6.4726 6.4041 6.4673 6.8241 7.0998 7.2014 7.2405 7.2353 7.2567 7.4398 7.4955 7.6592 7.7856 8.0679 8.1747 8.3866 8.3145 8.5703 8.451 8.4871 8.5268 8.7207 9.0143 8.9303 9.0791
The COMMONWEALTH FUND

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Pay for Performance and the Healthcare Value Paradigm

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