THE COMMONWEALTH FUND Karen Davis President, The Commonwealth Fund National Association of Community Health Centers Plenary Address March 27, 2006 [email protected]www.cmwf.org A Need to Transform the U.S. A Need to Transform the U.S. Health Care System: Improving Health Care System: Improving Access, Quality, and Efficiency Access, Quality, and Efficiency
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THE COMMONWEALTH FUND Karen Davis President, The Commonwealth Fund National Association of Community Health Centers Plenary Address March 27, 2006 [email protected].
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THE COMMONWEALTH
FUND
Karen DavisPresident, The Commonwealth Fund
National Association of Community Health CentersPlenary AddressMarch 27, [email protected]
A Need to Transform the U.S. Health A Need to Transform the U.S. Health Care System: Improving Access, Care System: Improving Access,
Quality, and EfficiencyQuality, and Efficiency
2
THE COMMONWEALTH
FUND
Need for Better Access, Higher Quality, and Need for Better Access, Higher Quality, and Greater EfficiencyGreater Efficiency
• The U.S. health system fails to provide access to care for all
– 46 million uninsured
– 16 million adults underinsured
• The U.S. health system fails to reliably deliver high quality care to all
– Only 55 percent of recommended care delivered
– Only half of adults received recommended preventive care
– One-third of sicker adults report medical, medication, or lab test error in past two years
• The U.S. health system is costlier than any other country, but fails to deliver superior value for money spent
3
THE COMMONWEALTH
FUND
Ten Keys to Transforming the U.S. Health Ten Keys to Transforming the U.S. Health Care SystemCare System
1. Agree on shared values and goals2. Organize care and information around the
patient3. Expand the use of information technology4. Enhance the quality and value of care5. Reward performance6. Simplify and standardize7. Expand health insurance and make coverage
automatic8. Guarantee affordability9. Share responsibility for health care financing10. Encourage collaboration
4
THE COMMONWEALTH
FUND
Community Health CentersCommunity Health CentersCan Lead the WayCan Lead the Way
Within own organizations• Organize care and information around the patient• Expand the use of information technology• Enhance the quality and value of care
By joining with others for policy change• Support Medicaid, CHIP, and Medicare• Expand health insurance and make coverage automatic
and affordable• Embrace change – transparency, public reporting, pay
for performance
5
THE COMMONWEALTH
FUND
Community Health Centers:Community Health Centers:Key Role in Caring for Most VulnerableKey Role in Caring for Most Vulnerable
6
THE COMMONWEALTH
FUND
Health Center Patients Are Predominantly Low-Health Center Patients Are Predominantly Low-Income, and Most are Uninsured or Have Income, and Most are Uninsured or Have
MedicaidMedicaid
Source: Bureau of Primary Health Care, 2003 Uniform Data System
Uninsured39%
Medicaid/ SCHIP36%
Medicare7%%
Other public
3%
Private15%
100% poverty
and below69%
101–150% poverty
14%
151–200% poverty
6%
Over 200% poverty
10%
Patients by Poverty Level Patients by Insurance Status
7
THE COMMONWEALTH
FUND
Racial and Ethnic Minorities Make Up Racial and Ethnic Minorities Make Up Two-Thirds of all Health Center PatientsTwo-Thirds of all Health Center Patients
A s ian/
Pac ific
Is lander
3%
White
36%
Hispanic /
Latino
35%
A fric an
A meric an
24%
A meric an Indian/
A laska Native
1%
Source: Bureau of Primary Health Care, 2002 Uniform Data System
8
THE COMMONWEALTH
FUND
Nearly One-Third of Health Center Patients Prefer Nearly One-Third of Health Center Patients Prefer Languages Other than EnglishLanguages Other than English
18% 19%23%
27% 28% 29% 30%
0%
10%
20%
30%
40%
50%
1997 1998 1999 2000 2001 2002 2003
Source: 1997-2002 Uniform Data System, BPHC, HRSA, DHHS.
Percent of users preferring languages other than English
9
THE COMMONWEALTH
FUND
Proportion of Vulnerable Populations at Proportion of Vulnerable Populations at Health Centers and in the U.S.Health Centers and in the U.S.
* Most recent year available. # For a family of three, $15,260 annual income in 2003 and %15,670 for in 2004.Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC Report, August 2005.
Health centers, 2004 U.S. Population, 2003*
Income
Less than 100% poverty#
71% 13%
Less than 200% poverty
91 31
Insurance status
Uninsured 40 16
Medicaid 36 12
Minority 64 32
10
THE COMMONWEALTH
FUND
Growth in Health Center Patients by Growth in Health Center Patients by Insurance Status, 1999-2004Insurance Status, 1999-2004
Source: National Association of Community Health Centers, Safety Net on the Edge, NACHC Report, August 2005.
5.34.9
4.44.03.9
3.74.7
4.44.0
3.63.2
2.91.91.81.71.61.51.4
1.00.90.80.70.70.7
0.30.40.40.30.3 0.30
1
2
3
4
5
6
1999 2000 2001 2002 2003 2004
U ninsured
Medic aid
P rivate
Medic are
Other public
In millions
11
THE COMMONWEALTH
FUND
Community Health Centers:Community Health Centers:A Leader in High Performance CareA Leader in High Performance Care
12
THE COMMONWEALTH
FUND
Increased Access of Uninsured to CareIncreased Access of Uninsured to Care
Health Center Patients
• 25% delayed care due to costs
• 16% went without needed care
• 12% could not fill Rx
Non-Health Center Patients
• 55% delayed care due to costs
• 30% went without needed care
• 24% could not fill Rx
Source: Politzer, R., et al. 2001. “Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care.” Medical Care Research and Review 58(2):234-248.
13
THE COMMONWEALTH
FUND
Ambulatory Care Sensitive Events by Regular Ambulatory Care Sensitive Events by Regular Source of CareSource of Care
Number of ACS events per 100 persons
Source: M. Falik et al., “Comparative Effectiveness of Health Centers as Regular Source of Care,” Journal of Ambulatory Care Management 29, no. 1 (November 26, 2005): 24-35.
6
26
8
38
0
25
50
75
ACS admiss ions ACS emergenc y vis its
Health c enters Other providers
14
THE COMMONWEALTH
FUND
Pap Tests by Race:Pap Tests by Race:Women Served by Community Health Women Served by Community Health Centers Compared to National SampleCenters Compared to National Sample
66
82
73
80
75
89
94
85
86
89
0 20 40 60 80 100
Other
B lac k Non-H ispanic
White Non-H ispanic
H ispanic
A ll Women
CHCNHIS Comparison Group
Source: Dan Hawkins, “Improving Minority Health and Reducing Disparities through the Health Disparities Collaboratives of America’s Community Health Centers,” Presentation to NAPH (June 24, 2005) Santa Fe, NM.
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THE COMMONWEALTH
FUND
Self-Reported Quality Assessment of Care Self-Reported Quality Assessment of Care Received at Health CentersReceived at Health Centers
Percent
Source: PEERS Report, NACHC analysis of PEERS, 1993-2001
41
55
40
63
36
1 10
25
50
75
Very
satisfied
Satisfied Dissatisfied Very
dissatisfied
1993 2001
16
THE COMMONWEALTH
FUND
Wait Times at Health Centers, 1993–2001Wait Times at Health Centers, 1993–2001
Source: PEERS Report, NACHC analysis of PEERS, 1993-2001
0
10
20
30
40
50
60
Under 15
minutes
15-30
minutes
31-59
minutes
1-3 hours 3+ hours
1993 2001
Percent of health center patients
17
THE COMMONWEALTH
FUND
Community Health Centers:Community Health Centers:Assuming a Leadership Role in A High Assuming a Leadership Role in A High
Performance Health SystemPerformance Health System
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THE COMMONWEALTH
FUND
Actions Community Health Centers Can Take to Actions Community Health Centers Can Take to Promote High PerformancePromote High Performance
• Organizing care and information around the patient– Patient-centered care
– Medical home or advanced primary care practice
– Advanced access
• Information technology
• Enhancing the quality and value of care– Chronic disease management
– Coordination of care
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THE COMMONWEALTH
FUND
Attributes of Patient-Centered Primary CareAttributes of Patient-Centered Primary Care• Superb access to care
– Quick appointments, short waiting times, accessible off-hours coverage, e-mail and telephone consultations
• Patient engagement in care – Information for patients on treatment and self-management plans,
preventive and follow-up care reminders, access to medical records, assistance with self-care
• Clinical information systems – Patient registries; monitor adherence to treatment; lab and test results;
decision support• Care coordination
– Coordination of specialist care, systems/processes to prevent errors in transitions, post-hospital follow-up
• Integrated and comprehensive team care– Excellent communication among physicians, nurses, and other health
professionals, and appropriate use of skills of all team members• Routine patient feedback to doctors
– Learn from patient-surveys and feedback• Publicly available information
– Patients have accurate, timely, complete information on physicians and other clinicians providing care
20
THE COMMONWEALTH
FUND
Insurance Status and Insurance Status and Continuity of Care with a Regular DoctorContinuity of Care with a Regular Doctor
Source: Karen Davis, Stephen C. Schoenbaum, Karen Scott Collins, Katie Tenney, Dora L. Hughes, and Anne-Marie J. Audet, Room for Improvement, The Commonwealth Fund, April 2002.
Same doctor for more than 5 years
18%
No regular doctor54%
Same doctor for fewer than 5 years
28%
No regular doctor19%
Same doctor for fewer than 5 years
47%
Same doctor for more than 5 years
34%
Uninsured adults (full or part year) Insured adults
21
THE COMMONWEALTH
FUND
People in Community Health Centers Who People in Community Health Centers Who Have a Usual Source of Care, 2002Have a Usual Source of Care, 2002
Source: AHRQ, “Focus on Federally Supported Health Centers,” National Healthcare Disparities Report, 2004. http://www.qualitytools.ahrq.gov/disparitiesReport/browse/browse.aspx?id=4981
98 98 98
0
25
50
75
100
Non-hispanic w hite A fric an A meric an Hispanic
Percent
22
THE COMMONWEALTH
FUND
Minorities Without a Regular DoctorMinorities Without a Regular DoctorAre More Likely to Use Emergency Room for Are More Likely to Use Emergency Room for
CareCare
16%
27%24%
14%
4%7% 7%
4%
0%
15%
30%
White A fric an
Americ an
Hispanic As ian
Americ an
No Regular Doc tor Regular Doc tor
Source: K.S. Collins et al., “Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans,” The Commonwealth Fund, March 2002
Percent reporting emergency room or no regular place of care
23
THE COMMONWEALTH
FUND
In U.S., Canada Adults Less Likely to Be Able to See In U.S., Canada Adults Less Likely to Be Able to See Physician Same Day and More Likely to Substitute ER Physician Same Day and More Likely to Substitute ER
for Regular Physician Carefor Regular Physician Care
54
918
60
7
41
6
33
16
27
0
25
50
75Percent
AUS CAN NZ UK US
Same day appointment Went to ER for condition that could have been
treated by regular doctor if available
AUS CAN NZ UK US
Source: 2004 Commonwealth Fund International Health Policy Survey
Access to Doctor When Sick or Needed Medical Attention
24
THE COMMONWEALTH
FUND
Primary Care Development CorporationPrimary Care Development CorporationPrimary Care Clinic Redesign Collaborative: Primary Care Clinic Redesign Collaborative:
Before RedesignBefore Redesign148 Minutes, 11 Steps148 Minutes, 11 Steps
FRONTDESK
CASHIER WAITINGROOM
NURSINGSTATION
WAITINGROOM
EXAM ROOMNURSINGSTATION
BATHROOM
LABFRONTDESK
FRONT DESK
CLERKEXIT
CASHIERWAITING
ROOMEXAMROOM
EXITFRONTDESK
After RedesignAfter Redesign50 Minutes, 4 Steps50 Minutes, 4 Steps
Source: Pamela Gordon, M.A., and Matthew Chin, M.P.A., Achieving a New Standard in Primary Care for Low-Income Populations: Case Study 1: Redesigning the Patient Visit, The Commonwealth Fund, August 2004
25
THE COMMONWEALTH
FUND
The PCDC Track RecordThe PCDC Track Record
Program Teams Outcomes
Redesign(7 Collabs)
77 • Cycle time: 109 to 53 minutes• “Waiting around” time: 106 to 0-
minimum.• Visits/hour/provider: 2.9 to 3.2
Advanced Access(5 Collabs)
24 • Days for next available appt: 21 to range of 0-5
Center for Shared Decision-MakingCenter for Shared Decision-Making Dartmouth-Hitchcock Medical Center Dartmouth-Hitchcock Medical Center
• Provides tools to assist with health care decisions (e.g., videotapes, booklets, websites)
• Provides follow-up counseling with skilled staff
• Seeks to be a prototype for health care systems nationwide
Kate Clay, BA, MSN, Program Director
27
THE COMMONWEALTH
FUND
3445
28
5140
40 4835
42
37
0
25
50
75
100
A US CA N NZ UK US
Do not have ac c ess to ow n medic al rec ords but w ould like to
H ave ac c ess to ow n medic al rec ordsPercent
Patient Access to Personal Health RecordsPatient Access to Personal Health Records
Source: The Commonwealth Fund 2004 International Health Policy Survey.
80 82 8070
88
28
THE COMMONWEALTH
FUND
1413
36
61
23 25
66
35 3746
57
87
0
25
50
75
100
Elec tronic ac c ess to
tes t results
E lec tronic medic al
rec ords
Elec tronic ordering
1 Phys ic ian 2–9 Phys ic ians 10–49 Phys ic ians 50+ Phys ic ians
Electronic Access to Patient Test Results & Electronic Access to Patient Test Results & Medical Records (EMRs), and Electronic Medical Records (EMRs), and Electronic
Ordering, by Practice SizeOrdering, by Practice Size
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
Percent who currently “routinely/occasionally” use the following
* Electronic ordering of tests, procedures, or drugs.
*
29
THE COMMONWEALTH
FUND
E.Wagner, MD
30
THE COMMONWEALTH
FUND
Health Disparities CollaborativesHealth Disparities Collaboratives• Goal: Implement in all 1,000 health centers by 2006
– 600 health centers nationwide participating– 250,000+ health center patients with chronic disease
enrolled in electronic registries • Chronic Care Model:
– Use of evidence-based care– Assure care continuity– Effectively involve patients in self-management– Completely re-design system to emphasize health
• Collaboratives– Training and technical assistance– Quality Improvement infrastructure– Partnerships at the local, state, and national level
• Commonwealth Fund co-funding evaluation with AHRQ – Bruce Landon Harvard
31
THE COMMONWEALTH
FUND
New York City Health and Hospitals Corporation:New York City Health and Hospitals Corporation:Diabetes Outcomes: HBA1c, Blood PressureDiabetes Outcomes: HBA1c, Blood Pressure
• Average A1C<7 increased from 30% to 42%
• 31% with BP 130/80 at baseline, increased to 57%
Mean A1C <7
0102030405060
Perc
ent
Mean BP <130/80
0102030405060
perc
ent
Source: Karen Scott-Collins, MD, MPH, Deputy Chief Medical Officer, Health Care Quality and Clinical Services, New York City Health and Hospitals Corporation
32
THE COMMONWEALTH
FUND
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
Percent indicating involvement in redesign and collaborative efforts
Physicians’ Participation in Redesign and Physicians’ Participation in Redesign and Collaborative Activities, by Practice SizeCollaborative Activities, by Practice Size
43
20
3339
50
32
47
35
24
34
0
50
100
Redesign Efforts Collaborative Efforts*
Total 10–49 Physicians1 Physician 50+ Physicians2–9 Physicians
* Indicates physicians who responded yes to participating in local, regional, or national collaboratives in the past 2 years.
33
THE COMMONWEALTH
FUND
Health Policy: Health Policy: Need for LeadershipNeed for Leadership
• Federal budget deficits harmful to U.S. economy in long-term
• Tax revenues as percent of GDP at 40 year low, yet further tax cuts are on the table
• Cuts to Medicaid have potential to harm access to health care for low-income beneficiaries; savings not used to expand coverage of uninsured
• Medicare privatization contributes to higher, not lower, costs and budget outlays; no solution to Medicare long-term fiscal problems
• Real solutions to grappling with nation’s health care problems not being considered
34
THE COMMONWEALTH
FUND
Tax Revenues at Lowest Percent of GDP Tax Revenues at Lowest Percent of GDP in 40 Yearsin 40 Years
Note: Actual 1962–2004; Projected 2005–2015.Source: Congressional Budget Office, The Budget and Economic Outlook: Fiscal Years 2006 to 2015, January 2005.
Average Annual Medicaid Spending Growth Per Average Annual Medicaid Spending Growth Per Enrollee Lower Than Private Health Spending, Enrollee Lower Than Private Health Spending,
2000–2003 2000–2003
6.9
9.0
12.6
0
2
4
6
8
10
12
14
Medicaid acute care
spending per enrollee
Health care spending
per person with
private coverage
Monthly premiums for
employer-sponsored
insurance
Percent average annual growth
Source: J. Holahan and A. Ghosh, “Understanding the Recent Growth in Medicaid Spending, 2000–2003,” Health Affairs Web Exclusive, January 26, 2005; B.C. Strunk and P.B. Ginsburg, “Trends: Tracking Health Care Costs: Trends Turn Downward In 2003,” Health Affairs Web Exclusive, June 9, 2004; Kaiser/HRET, Employer Health Benefits 2003 Annual Survey, 2003
36
THE COMMONWEALTH
FUND
Higher Deductibles Associated with Greater Higher Deductibles Associated with Greater Access ProblemsAccess Problems
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.**Health problem defined as fair or poor health or one of eight chronic health conditions.Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
Percent of adults ages 21-64 who have delayed or avoided getting health care due to cost
• Administration policy provides for:– Tax incentives for the
purchase of high deductible health plans
– Tax credits for low-income uninsured individuals and families
• Minor effect on uninsured (e.g. 2-3 million out of 46 million uninsured)
• Almost no effect on rising health care costs
• Likely to increase “underinsurance” and pose barriers to care for low-income and chronically ill
26
2117
42
313135
48
40
0
20
40
60
Total Health Problem** <$50,000 AnnualIncome
Comprehensive HDHP CDHP
37
THE COMMONWEALTH
FUND
Percent of Adults Ages 18–64 UninsuredPercent of Adults Ages 18–64 Uninsuredby Stateby State
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
MARI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DE
DC
HI
CO
GAMS
OK
NJ
SD
19%–23.9%
Less than 14%
14%–18.9%
24% or more
1999–2000 2003–2004
Source: Two-year averages 1999–2000 and 2003–2004 from the Census Bureau’s March 2000, 2001 and 2004, 2005 Current Population Surveys. Estimates by the Employee Benefit Research Institute.
MA
RI
CT
VTNH
MD
38
THE COMMONWEALTH
FUND
Without Insurance it Is Difficult to Obtain Without Insurance it Is Difficult to Obtain Specialized Care Specialized Care
Source: M.K. Gusmano, G. Fairbrother, and H. Park, “Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured,” Health Affairs 21, no. 6 (Nov./Dec. 2002): 188–94.
0 20 40 60 80 100
Uninsured patients
Insured patientsCan provide all necessary services
using health center's resources
Can obtain non-emergency admissions
Can obtain specialty referrals
39
THE COMMONWEALTH
FUND
Proportion of U.S. Physicians Providing Charity Proportion of U.S. Physicians Providing Charity Care Is DecliningCare Is Declining
76.368.271.5
0
25
50
75
100
1996-97 2000-01 2004-05
Percent
* Change from 2000-01 is statistically significant at p<.05# Change from 1996-977 is statistically significant at p<.05Source: P.J. Cunningham and J.H. May, “A Growing Hole in the Safety Net: Physician Charity Care Declines Again,” Center for Studying Health System Change, Tracking Report No. 13, March 2006.
##*
40
THE COMMONWEALTH
FUND
Retaining and Expanding Employer Retaining and Expanding Employer Participation: Maine’s Dirigo HealthParticipation: Maine’s Dirigo Health
• New insurance product; $1250 deductible; sliding scale deductibles and premiums below 300% poverty
• Employers pay fee covering 60% of worker premium
• Began Jan 2005; Enrollment 11,000 as of 10/20/05
* After discount and employer payment (for illustrative purposes only).
300600
8881188
1488
1250
0
1000
750
500
250
0$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
MaineCare <150% <200% <250% <300% >300%
Deduc tible amountEmployee share of annual premium
Annual expenditures on deductible and premium
$550
$0
$1,100
$1,638
$2,188
$2,738
41
THE COMMONWEALTH
FUND
Pay for Performance ProgramsPay for Performance Programs• There are almost 90 pay-for-performance programs across the U.S.
– Provider driven (e.g., Pacificare)– Insurance driven (e.g., BC/BS in MA)– Employer driven (e.g., Bridges to Excellence – Verizon, GE,
Ford, Humana, P&G, and UPS)– Medicare
• 2003 Medicare Rx legislation demonstrations of Medicare physicians a per-beneficiary bonus if specified quality standards are met
– Medicaid• RIte Care will pay about 1% bonus on its capitation rate to
plans meeting 21 specified performance goals• 4 other states built performance-based incentives into
Medicaid contracts – UT, WI, IO, MA• Evaluation of impact still pending
Source: Leapfrog report for Commonwealth Fund; additional information available at http://www.leapfroggroup.org/
42
THE COMMONWEALTH
FUND
Building Quality Into RIte CareBuilding Quality Into RIte CareHigher Quality and Improved Cost TrendsHigher Quality and Improved Cost Trends
• Quality targets and $ incentives
• Improved access, medical home
– One third reduction in hospital and ER
– Tripled primary care doctors
– Doubled clinic visits
• Significant improvements in prenatal care, birth spacing, lead paint, infant mortality, preventive care
Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003. Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005.
Cumulative Health Insurance Rate Trend
Comparison
0
20
40
60
80
100
120
140
160
RI Commercial Trend
RIte Care Trend
Percent
43
THE COMMONWEALTH
FUND
Take Away MessagesTake Away Messages• Closing gaps in insurance coverage is the number one priority
action to improve care for vulnerable populations– Support Medicaid funding– Support expansion of insurance coverage– Support adequate funding of primary care capacity in low-
income underserved communities• Promote patient-centered primary care
– Make it easy to get appointments and obtain care– Shared decision-making can help improve and coordinate
care, and engage patients as active partners in their care• Invest in information technology • Invest in chronic care quality improvement
– Share best practices– Join learning collaboratives to improve care
• Embrace transparency, public reporting, and pay for performance
44
THE COMMONWEALTH
FUND
Thank You!Thank You!
• Stephen C. Schoenbaum, M.D., Executive Vice President and Executive Director, Commonwealth Fund Commission on a High Performance Health System
• Anne Gauthier, Senior Policy Director, Commonwealth Fund Commission on a High Performance Health System
• Alyssa L. Holmgren, Research Associate, Commonwealth Fund