Americans are spending more on health care as quality and access fall
Despite spending 16% of its gross domestic product on health care, double the median of industrialized countries, the United States is the only major industrialized country that fails to guarantee universal health insurance, insurance coverage is deteriorating, and the U.S. health system is not the best in quality of care and not a leader in health information technology.
That's the conclusion drawn by Commonwealth Fund researchers who pulled together a national health system performance scorecard for use by the fund's Commission on a High Performance Health System.
"The findings indicate that America's health system falls far short of what is attainable, especially given the resources the nation invests," the report said. "Across 37 indicators of performance, the United States achieves an overall score of 66 out of a possible 100 when comparing actual national performance to achievable benchmarks. Scores on efficiency are particularly low."
According to Commonwealth Fund senior vice president for research and evaluation Cathy Schoen, the lead author on the report, who spoke at an Alliance for Health Reform briefing on the study, failure to reach benchmark rates "accounts for as much as $50 billion to $100 billion of wasted money per year and 100,000 to 150,000 lives. And this doesn't count the cost in terms of sick days and lost productivity."
Commonwealth Fund President Karen Davis, who also worked on the study, said the scorecard shows that every state has room to improve its health care system, but it is especially critical that low-performing states learn from the innovative strategies being tested in higher-performing states so they can apply often scarce resources in pursuit of reforms that will really help improve the health of their residents.
The scorecard assessed how well the U.S. health system is performing as a whole, relative to what is achievable. It gave benchmarks for the nation and a mechanism for monitoring change over time across core health care system goals of health outcomes, quality, access, efficiency, and equity.
"If performance in the U.S. was uniform for each of the health system goals, and if, in those instances in which U.S. performance can be compared with other countries, we were consistently at the top, the average score for the U.S. would be 100," the report said. "But, the U.S. as a whole scores an average of 66. Several different measures or indicators were examined for each of the goal areas and dimensions of health system performance. There are wide gaps between national average rates and benchmarks in each of the dimensions of the scorecard, with U.S. average scores ranging from 51 to 71. By showing the gaps between national performance and benchmarks that have been achieved, the scorecard offers performance targets for improvement. And it provides a foundation for the development of public and private policy action, and a yardstick against which to measure the success of new policies."
Some major findings included:
- Long, Healthy, and Productive Lives — Total Average Score 69. The United States, the scorecard said, is one-third worse than the best country on mortality from conditions "amenable to health care," deaths that could have been prevented with timely and effective care. The infant mortality rate of 7.0 deaths per 1,000 live births compares poorly to the 2.7 deaths per 1,000 live births in the top three countries. The U.S. average adult disability rate is one-fourth worse than the best five U.S. states, as is the rate of children missing 11 or more days of school because of illness or injury.
- Quality — Total Average Score 71. Only 49% of adults receive preventive and screening tests according to guidelines for their age and sex. The current gap between national average rates of diabetes and blood pressure control and rates achieved by the top 10% of health plans translates into an estimated 20,000 to 40,000 preventable deaths and $1 billion to $2 billion in avoidable medical costs. Nursing home hospital admission and readmission rates in the bottom 10% of states are two times higher than in the top 10% of states.
- Access—Total Average Score 67. In 2003, 35% of adults younger than age 65 (61 million people) were either underinsured or uninsured at some time in the year. And 34% of all adults younger than 65 have problems paying their medical bills or have medical debt they are paying off over time.
- Efficiency—Total Average Score 51. National preventable hospital admissions for patients with diabetes, congestive heart failure, and asthma were twice the level achieved by the top states. Hospital 30-day readmission rates for Medicare patients ranged from 14% to 22% across regions. Bringing readmission rates down to the levels achieved by the top performing regions would save Medicare $1.9 billion annually. As a share of total health expenditures, U.S. insurance administrative costs were more than three times the rates of countries with the most integrated insurance systems. And the United States lags well behind other nations in use of electronic medical records, with 17% of U.S. doctors using them, compared with 80% in the top three countries.
- Equity—Total Average Score 71. On multiple indicators across quality of care and access to care, there is a wide gap between low-income or uninsured populations and those with higher incomes and insurance. On average, low-income and uninsured rates would need to improve by one-third to close the gap. On average, it would require a 20% decrease in Hispanic risk rates to reach benchmark white rates on key indicators of quality, access, and efficiency. Overall, it would require a 24% or greater improvement in African American mortality, quality, access, and efficiency indicators to approach benchmark white rates.
- System Capacity to Innovate and Improve—Not Scored. The current federal investment in health services research, estimated at $1.5 billion, amounts to less than $1 out of every $1,000 in national health care spending. Ideally, the report said, a scorecard would include indicators of the system's capacity to innovate and improve, but good indicators in this area are not currently available, and that is in itself a problem.
"The scorecard makes a compelling case for change," the report said. "Simply put, we fall far short of what is achievable on all major dimensions of health system performance. The overwhelming picture that emerges is one of missed opportunities—at every level of the system—to make American health care truly the best that money can buy.
"These results are not just numbers. Each statistic—each gap in actual vs. achievable performance—represents illness that can be avoided, deaths that can be prevented, and money that can be saved or reinvested. In fact, if we closed just those gaps that are described in the scorecard, we could save at least $50 billion to $100 billion per year in health care spending and prevent 100,000 to 150,000 deaths. Moreover, the nation would gain from improved productivity."
Points to ponder
The Commonwealth Fund said the scorecard's central messages are:
- universal coverage and participation are essential to improve quality and efficiency, as well as access to needed care;
- quality and efficiency can be improved together;
- failure to coordinate care for patients over the course of treatment puts patients at risk and raises the cost of care;
- financial incentives posed by the fee-for-service system of payment as currently designed undermine efforts to improve preventive and primary care, manage chronic conditions, and coordinate care;
- research and investment in data systems are important keys to progress;
- savings can be generated from more efficient use of expensive resources, including more effective care in the community to control chronic disease and assure patients timely access to primary care;
- setting national goals for improvement based on achieved rates is likely to be an effective method to motivate change and move the overall distribution to higher levels.
In a Health Affairs Web exclusive report on the scorecard, Ms. Schoen and her colleagues said the scorecard is a starting point for a national discussion. In many cases, the researchers said, desired data to represent an important concept were not available. By necessity, the scorecard includes some indicators for which data were available only with a time lag or for segments of the insured population. "The absence of good data on critical areas and fragmented sources are symptomatic of lower-than-desirable system performance," they concluded.
At the Alliance for Health Reform briefing, Ms. Schoen said that given the amount of money being spent on health care in the United States, "we should expect to do much better, but we rank poorly even when we look within our own country and benchmark to ourselves."
She said guaranteed affordable health insurance is a foundation for doing better in quality, access, and efficiency. A significant problem, she said, is that, except for the Medicare population, insurers often don't know anything about their patients for very long because they lose them.
"They can't track a diabetic patient over time." Ms. Shoen said. "There is very little incentive to invest for long-term gains and for the future. We don't have databases where we can access care and the churning also raises overall costs and leads to gaps in care. Quality and efficiency can be joint goals. We see throughout the United States instances where higher quality is associated with lower costs."
Commonwealth Fund executive vice president for programs Stephen Schoenbaum said that while reasonable people can debate over the meaning of an overall score of 66, to the Commonwealth Fund the message is quite clear: "We need to do better and we can do much better. The scorecard presents the evidence for both of those statements in that the benchmark data tell us that in some regions, states, or organizations in this nation or abroad, higher levels of performance are being achieved for each of these indicators. So ask yourself, why not the best for all Americans. As a physician, I see the scorecard findings as the diagnosis and the Commission on a High Performance Health System has already begun to map out a treatment plan."
Bringing a different perspective to the conversation, American Enterprise Institute resident fellow Tom Miller told the briefing that much of the variation in care uncovered in the scorecard is "natural, particularly in a pluralistic provider system spread across 50 states. Setting an unrealistic bar of reaching the 10% threshold detracts from the more important goal of providers improving their own respective performance levels. The goals need to be a combination of relative and absolute improvement."
Likewise, Elizabeth Hall, health policy director for Senate Republican leader Bill Frist, said that when people need health care, they go to their personal physician's office and not to a health care system.
"While it's important to have system-level information and bring system-level information together, I think what we as policy-makers are pushing for and need much more is individual provider-level information on who is the best provider for the condition I have, who has the best outcomes, who can see me most quickly, and who, quite frankly, do I like and get along with."
Ms. Hall said the scorecard raises four issues for her: 1) the importance of measuring quality, cost, performance, process, and outcomes at a very granular level and actually look at individual providers; 2) value doesn't come just from measuring and collecting information, but also from making information available; 3) standards are needed if health care technology uptake is to increase; and 4) it is necessary to take steps to remove barriers and provide incentives for health care providers to actually use health information technology.
The Commonwealth Fund scorecard is available on-line at www.cmwf.org. The Health Affairs report is on-line at www.healthaffairs.org. Contact Ms. Davis, Ms. Schoen, and Mr. Schoenbaum at (212) 606-3800.
Despite spending 16% of its gross domestic product on health care, double the median of industrialized countries, the United States is the only major industrialized country that fails to guarantee universal health insurance.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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