Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011

October 18, 2011

Authors: The Commonwealth Fund Commission on a High Performance Health System
Contact: Cathy Schoen, M.S., Senior Vice President for Policy, Research, and Evaluation, The Commonwealth Fund cs@cmwf.org


National Scorecard



The National Scorecard on U.S. Health System Performance, 2011, updates a series of comprehensive assessments of U.S. population health and health care quality, access, efficiency, and equity. It finds substantial improvement on quality-of-care indicators that have been the focus of public reporting and collaborative initiatives. However, U.S. health system performance continues to fall far short of what is attainable, especially given the enormity of public and private resources devoted nationally to health. Across 42 performance indicators, the U.S. achieves a total score of 64 out of a possible 100, when comparing national rates with domestic and international benchmarks. Overall, the U.S. failed to improve relative to these benchmarks, which in many cases rose. Costs were up sharply, access to care deteriorated, health system efficiency remained low, disparities persisted, and health outcomes failed to keep pace with benchmarks. The Affordable Care Act targets many of the gaps identified by the Scorecard.

Executive Summary

As the United States implements national health care reforms, it is instructive to take stock of how well our health system is able to provide access to high-quality, efficiently delivered care. Evidence from the new 2011 edition of the National Scorecard on U.S. Health System Performance shows substantial erosion in access to such care in the period leading up to health reform, along with rising costs that are stressing families, businesses, and all levels of government. Variations in health care delivery, moreover, persist throughout the U.S., as opportunities are routinely missed to prevent disease, disability, hospitalization, and mortality. At the same time, the Scorecard finds notable gains in quality of care in those areas where the nation has made a commitment to accountability and undertaken targeted improvement efforts.

Based on the Scorecard's 42 indicators of health system performance, the U.S. earned an overall score of 64 out of a possible 100 when comparing national averages with benchmarks of best performance achieved internationally and within the U.S. Although the Scorecard draws on the latest available data, primarily from the period 2007 to 2009, the results do not fully reflect the effects of the recent economic recession on access to and use of care. The overall performance on the indicators failed to improve relative to benchmarks since the first National Scorecard was issued in 2006, or since the last update in 2008. Benchmarks, however, improved in many cases, raising the bar on what is attainable.

Some good news can be found in an exception to the overall pattern of U.S. performance: rapid progress on quality metrics that have been the focus of national initiatives and public reporting efforts. Hospitals, nursing homes, and home health care agencies are showing marked improvement in patient treatment and outcomes for which data are collected and reported nationally on federal Web sites and as part of improvement campaigns. There has also been significant improvement in the control of high blood pressure, a measure that is publicly reported by health plans; increasingly, physician groups are being rewarded for improving their treatment of this and other chronic conditions. Better management of chronic diseases also has likely contributed to reductions in rates of avoidable hospitalizations for certain conditions, though rates continue to vary substantially across the country.

Of great concern, access to health care significantly eroded since 2006. As of 2010, more than 81 million working-age adults—44 percent of those ages 19 to 64—were uninsured during the year or underinsured, up from 61 million (35%) in 2003. Further, the U.S. failed to keep pace with gains in health outcomes achieved by the leading countries. The U.S. ranks last out of 16 industrialized countries on a measure of mortality amenable to medical care (deaths that might have been prevented with timely and effective care), with premature death rates that are 68 percent higher than in the best-performing countries. As many as 91,000 fewer people would die prematurely if the U.S. could achieve the leading country rate.

Sharply rising costs are putting both access and budgets at risk. Health care spending per person in the U.S. is double that in several other major industrialized countries, and costs in the U.S. continue to rise faster than income. We are headed toward spending $1 of every $5 of national income on health care. We should expect a better return on this investment.

Performance on indicators of health system efficiency remains especially low, with the U.S. scoring 53 out of 100 on measures that gauge the level of inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. Lowering insurance administrative costs to benchmark country rates could alone save up to $114 billion a year, or $55 billion if such costs were lowered to the level in countries with a mixed private–public insurance system, like the U.S. has.

The lack of improvement on many health system indicators—such as preventive care, adults and children with strong primary care connections, and hospital readmissions—likely stems from the nation's weak primary care foundation and from inadequate care coordination and teamwork both across sites of care and between providers. These gaps highlight the need for a whole-system approach, in which performance is measured and providers are held accountable for performance across the continuum of care.

To produce greater value from the resources the nation devotes to health care, action is urgently needed to improve access to care and the performance of the care delivery system. Provisions in the Affordable Care Act target many of the gaps identified by the National Scorecard, particularly access, affordability, and support for innovations to make care more patient-centered and coordinated. Scorecard indicators in each of these areas provide a baseline for monitoring performance over time and assessing whether these reforms and others being pursued in the public and private sectors succeed in closing performance gaps.