In the Literature
Despite health expenditures that are twice those of the median industrialized country, a new national scorecard of U.S. health care system performance finds the nation falls short on key indicators of health outcomes, quality, access, efficiency, and equity. Findings, published as a Health Affairs Web Exclusive, paint a disturbing picture of missed opportunities, as well as evidence the United States can do better on all fronts.
The article, "U.S. Health System Performance: A National Scorecard" (Health Affairs Web Exclusive, Sept. 20, 2006), written by The Commonwealth Fund's Cathy Schoen and colleagues, presents the results of the National Scorecard on U.S. Health System Performance, the first of its kind to assess the country's health care system across all critical domains. The Scorecard was developed by the Commonwealth Fund Commission on a High Performance Health System, which has issued an accompanying report examining the results and their implications.
U.S. Health System Scores a 66 Overall
Overall, the U.S. health care system scored an average 66 out of a maximum 100, based on 37 indicators of health outcomes, quality, access, efficiency, and equity. National performance was measured relative to benchmarks based on rates achieved by top countries or the top 10 percent of U.S. regions, states, hospitals, health plans, or other providers. Relative to the benchmarks, U.S. performance averages near 50 for efficiency and around 70 for other domains.
To create the Scorecard, researchers used a framework developed by the Institute of Medicine and drew from indicators used by a wide range of experts, as well as new indicators designed for the Scorecard. The Scorecard will continue to monitor performance over time, with benchmarks providing targets for improvement.
Substantial Room for Improvement
A central goal of the health care system is its capacity to contribute to long, healthy, and productive lives. In the Scorecard, this goal is measured by a series of indicators on health outcomes like preventable mortality, life expectancy, and certain health-related limitations faced by adults and children. The U.S. scored 69 out of 100 in this area, with wide variations in performance seen across the country.
Among 19 industrialized countries, the U.S. ranked 15th on "mortality from conditions amenable to health care," or deaths before age 75 that are potentially preventable with timely, effective care. The U.S. rate was more than 30 percent worse than the benchmark—the top three countries. The U.S. also ranks at the bottom for healthy life expectancy and last on infant mortality.
In terms of access to care, including health system participation and affordability of care, the Scorecard revealed generally poor performance. The authors say this is primarily a result of rising rates of uninsured and "underinsured" Americans, as well as health care costs that are outstripping growth in median income.
In the area of health system efficiency, the U.S. scored only 51. Efficiency indicators illustrate that quality, access, and costs are interconnected: poor quality often contributes to higher costs (through higher hospital readmission rates, for example), and poor access undermines quality, while simultaneously contributing to less-efficient care. Efficiency scores also reflect the nation's low use of electronic medical records and relatively high insurance administrative costs.
Performance Widely Variable
Across indicators, there was often a substantial spread between the top and bottom group of states, hospitals, or health plans, with those at the bottom well below the leaders and the national average. For instance, patients discharged from the hospital with congestive heart failure receive written discharge instructions—a measure of well-coordinated care—only 50 percent of the time, on average. There is an 80-percentage-point spread between the top and bottom 10 percent of hospitals, with the top group at 87 percent and the lowest-performers at 9 percent. On certain indicators, simply raising the bottom of the distribution to average performance would yield substantial net national gains, the authors say.
Improving Quality and Saving Lives
Overall, the Scorecard makes a compelling case for fundamental change in the nation's health care system. In addition to saving lives and reducing preventable complications, a better coordinated, more accessible system of care could achieve substantial savings with a net gain in value. The Scorecard provides evidence that quality and efficiency can be improved together: more efficient use of expensive resources can produce the same or better quality care at lower cost.
Moving forward, however, requires policies that address the interaction of access, quality, and cost and take a strategic, whole-system view—rather than a fragmented approach to change. The authors conclude that investment in information capacity as well as guaranteeing affordable health insurance will be essential to progress. With cost and coverage vital signs moving in the wrong direction, say the authors, the nation's health system is in urgent need of transformation.
Facts and Figures
- U.S. mortality for conditions amenable to health care is 115 per 100,000 people, compared with 80 per 100,000 in the top-performer among 19 countries.
- Barely half of U.S. adults receive all recommended clinical screening tests and preventive care, according to national guidelines.
- Thirty-day hospital readmission rates are more than 50 percent greater in those regions of the country with the highest rates than in regions with the lowest rates.
- One-third of adults under age 65 are uninsured or underinsured. A similar proportion have problems paying medical bills or are in medical debt.
- Disparities are pervasive: Black, Hispanic, low-income, and uninsured patients are less likely than white, high-income, and insured patients to receive recommended care, and more likely to be admitted to the hospital for potentially preventable conditions.