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Testimony--Closing the Quality Chasm: Opportunities and Strategies for Moving Toward a High Performance Health System

Executive Summary

As the nation turns to the issue of reforming our health insurance system, it is important to address simultaneously how we organize and deliver health services—to ensure that we are obtaining the best possible health outcomes for Americans and the most value for the money we spend on health care. Unfortunately, the care we receive falls short of the care it is possible to deliver, and the gap is not narrowing. According to the most recent National Scorecard published by the Commonwealth Fund Commission on a High Performance Health System, the U.S. health system in 2008 scored 65 out of 100 possible points on 37 indicators of performance capturing key dimensions of health outcomes, quality, access, equity, and efficiency.

The scorecard shows that the U.S. is not making consistent progress in reducing the variability of health care quality and is failing to keep pace with gains in health outcomes achieved by our industrialized peers:

  • The nation now ranks last out of 19 countries on a measure of "mortality amenable to medical care"—in five years falling from 15th, as other countries raised the bar on performance.
  • The widening quality chasm is having real effects on people's lives. Up to 101,000 deaths could be prevented each year if the U.S. raised standards of care to benchmark performance levels achieved abroad.
  • While we spend more than twice what other nations spend on health, there is overwhelming evidence of inappropriate care, missed opportunities, and waste within the U.S. health system.

We are fortunate, however, that even within our imperfect system, models exist for each of the components that—if properly organized, reformed, and financed—can enable the nation to provide high-quality, affordable care to every American. The following examples of excellence from across the U.S. and around the world offer insight into what it takes to achieve high performance:

  • A leader in innovation and quality improvement, the Geisinger Health System, on whose board I am pleased to serve, demonstrates the importance of simultaneously aligning incentives, utilizing electronic health records, and creating policies to encourage coordination of care.
  • Denver Health, a comprehensive and integrated medical system that is Colorado's largest health care safety-net provider, has succeeded by promoting a culture of continuous quality improvement and "lean" efficiency, adopting information technology, and providing organization-wide leadership.
  • State initiatives in Iowa and Vermont have achieved better health outcomes and increased access to needed health services by encouraging adoption of the medical home model, disseminating performance information and best practices, and launching focused campaigns to cover young children.
  • Regional associations like the Massachusetts Health Quality Partners and the Wisconsin Collaborative for Healthcare Quality have become leaders in quality improvement by collecting and disseminating performance data on hospitals and physician groups and by educating providers and patients to use that information to facilitate improvement activities.
  • Denmark and the Netherlands have become international leaders in patient-centered, coordinated care by placing great emphasis on accessible primary care and developing information systems that assist primary care physicians in coordinating health services.

The specific policies that will both lead to better health outcomes and "bend the curve" of our nation's unsustainable health care spending revolve around five strategies that are amenable to action at the federal level:

  • Provide affordable health coverage for all;
  • Reform provider payment;
  • Organize our care delivery systems;
  • Invest in a modern health system; and,
  • Ensure strong national leadership.

Congress can continue to develop the infrastructure for improving quality by making investments in health information technology and information exchange networks. If the U.S. is serious about closing the quality chasm, it will also need a strong primary care system, which requires fundamentally reforming provider payment, encouraging all patients to enroll in a patient-centered medical home, and supporting physician practices that serve as medical homes with information technology and technical assistance for redesigning care processes. Funding for research on comparative effectiveness and establishing a center for comparative effectiveness are also crucial to value-based purchasing and performance-improvement initiatives. Finally, the federal government can raise the bar for health system performance by setting explicit goals and priorities for improvement—particularly with regard to the most prevalent chronic conditions, which account for a large majority of health care costs.

By applying these policies collectively, the nation would be able to capture the synergistic benefits of specific changes that, if implemented individually, would yield more modest improvements in quality and smaller reductions in projected spending. And, to be sure, any reforms must support health care providers in their efforts to deliver the best care possible for their patients.

Armed with the knowledge that the status quo is no longer acceptable, we have entered a new era ripe with opportunity to close the quality chasm and improve the health and well-being of American families. Working together, we can change course and put the U.S. health system on a path to high performance.

Publication Details



K. Davis, Closing the Quality Chasm: Opportunities and Strategies for Moving Toward a High Performance Health System, Invited Testimony, Senate Committee on Health, Education, Labor, and Pensions, Hearing on "Crossing the Quality Chasm in Health Care Reform," January 29, 2009.