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Headed in the Wrong Direction: The 2008 National Scorecard on U.S. Health System Performance

Belief in economic and scientific progress is deeply engrained in the American way of life. As residents of a "can do" nation, Americans expect that our children will be better off than their parents, and that scientific breakthroughs will eventually conquer disease. Evidence that health care in this country is slipping backward is, therefore, deeply troubling.

Despite the best efforts of millions of talented and dedicated health care professionals, The Commonwealth Fund's latest Commission on a High Performance Health System National Scorecard on U.S. Health System Performance demonstrates that, in fact, we are losing ground. The first Scorecard was published in 2006. The new Scorecard, published this month, finds disturbing evidence that the health system is on the wrong track. In nearly every category measured, the health system performs worse than two years ago—scoring just 65 out of 100 across 37 indicators, where 100 represents not what is ideal but what has actually been achieved in some places for some groups of people.

The Scorecard takes a broad look at how well the U.S. health care system is doing, where improvements are needed, and what examples of good care exist that could serve as models for the rest of the country. It looks at specific issues: Do people have access to the health care they need? Are they getting the highest-quality care, and are we spending money and using health care resources efficiently?

One of the primary reasons for the system's poor performance is worsening access to care. In 2007, more than 75 million adults—42 percent of all adults ages 19 to 64—were either uninsured or underinsured during the year, up from 35 percent in 2003. This means that millions of Americans are unable to get the care they need.

The Scorecard also found evidence that the billions spent on U.S. health care—far more than any other industrialized country—are often squandered on administrative costs, inefficient systems, wasteful care, or treatment of preventable conditions.

The U.S. also failed to keep up with advances in health outcomes, falling from 15th to 19th among industrialized nations in terms of the number of premature deaths that could potentially have been prevented by timely access to care.

The good news? There have been some gains in the quality of care. Performance on a key measure of patient safety—hospital standardized mortality ratios, which were targeted in the Institute for Healthcare Improvement's "100,000 Lives campaign"—improved significantly, by 19 percent from 2000–2002 to 2004–2006. Moreover, hospitals are increasingly meeting evidence-based treatment guidelines, for which data are collected and reported on a Medicare Web site. Rates of control of two common chronic conditions, diabetes and high blood pressure, also have improved significantly. These measures are publicly reported by health plans, and physician groups are increasingly rewarded for improving treatment of these conditions. So improvement is possible, but it takes leadership, concerted action, and monitoring of progress.

If the U.S. health system achieved benchmark levels of performance, there would be real benefits in terms of health, patient experiences, and savings. For example:

  • Thirty-seven million more adults would have an accessible primary care provider, and 70 million more adults would receive all recommended preventive care.
  • 100,000 fewer people would die from causes that could have been prevented by good care.
  • The Medicare program could potentially save at least $12 billion a year by reducing readmissions or reducing hospitalizations for preventable conditions.
  • If we could lower the administrative costs of health insurances to the level found in Germany, which like the U.S. has a blended public–private health system, we could save $51 billion a year. Reaching levels achieved in the best performing countries would save an estimated $102 billion per year.

These and other findings make a compelling case for change in the way U.S. health care is financed, organized, and delivered. A new Presidential administration in 2009 will provide a historic opportunity to change direction. A comprehensive strategy that simultaneously aims to ensure health insurance for all, improve quality, and achieve greater efficiency is needed to close gaps in performance. The goal should be a 2010 National Scorecard that lives up to the best of what is possible with American ingenuity and the considerable resources invested in our health sector.

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July 2008


Written with the assistance of Martha Hostetter


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