Runaway train: U.S. health system gaining speed 'on the wrong track'
Access to health care declining significantly
The Commonwealth Fund's 2008 update to its initial National Scorecard on U.S. Health System Performance, issued in 2006, contains a sobering assessment that health care in this country typically falls far short of what is achievable. "Even more troubling," the report declares, "the U.S. health system is on the wrong track. Overall, performance has not improved since the first National Scorecard was issued in 2006. Of greatest concern, access to health care has significantly declined."
Commonwealth Fund president Karen Davis tells State Health Watch that she and the other scorecard authors feel "disappointment that the U.S. is not making headway" with many of the major scorecard elements. "Typically, when you work on things they get better," she ruefully says. "But the improvements we see are dwarfed by the areas in which we are losing ground, especially access."
As of 2007, the researchers found, more than 75 million adults42% of all adults between ages 19 and 64were either uninsured or underinsured during the year, up from 35% in 2003. At the same time, the United States failed to keep pace with gains in health outcomes achieved by leading countries around the world. Thus, the U.S. now ranks last out of 19 countries on a measure of mortality amenable to medical care, falling from 15th place even as other countries raised the bar on performance. If the U.S. overall could match the leading benchmark within this country and internationally, Ms. Davis asserts, 101,000 fewer people would die prematurely.
The scorecard also found evidence that the billions of dollars spent on U.S. health care, far more than in any other industrialized country, often are squandered on administrative costs, inefficient systems, wasteful care, or treating preventable conditions.
The brightest spot in the updated scorecard was in quality metrics that have been the focus of national campaigns or public reporting. For example, hospital standardized mortality rates, a key patient safety measure, improved by 19% from 2000-2002 to 2004-2006. The report says this sustained improvement followed widespread availability of risk-adjusted measures coupled with several high-profile local and national programs to improve hospital safety and reduce mortality. Hospitals also are showing measurable improvement on basic treatment guidelines for which data are collected and reported nationally on federal web sites. Diabetes and hypertension control rates also have improved significantly. These measures are publicly reported by health plans and physician groups are increasingly rewarded for results in improving treatment of these conditions.
Spend more, get less
The researchers found that the U.S. spends twice per capita what other major industrialized countries spend on health care, and costs continue to rise faster than income. Performance on measures of health system efficiency remains especially low, with the United States scoring 53 out of a possible 100 on measures gauging inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. The report says national leadership is urgently needed to yield greater value for the resources being devoted to health care.
"The continuing deterioration of our health care system and the growing recognition that we aren't getting value for what we spend will force change," Ms. Davis says.
The National Scorecard includes 37 indicators in five dimensions of health system performance: healthy lives, quality, access, efficiency, and equity. Rather than choosing artificial standards, the authors compare U.S. average performance with benchmarks drawn from the top 10% of U.S. states, regions, health plans, hospitals, or other providers or top-performing countries, with a maximum possible score of 100.
In 2008, the United States as a whole scored only 65, down from a score of 67 in 2006, well below the achievable benchmarks. Average scores on the five dimensions ranged from a low of 53 for efficiency to 72 for healthy lives.
Overall, national scores declined for 41% of indicators, while 35% improved and the rest remained static or were not updated (see sidebar). As observed in the 2006 scorecard, the bottom group of hospitals, health plans, or geographic regions often is well behind even average rates, with as much as a fivefold spread between top and bottom rates. On key indicators, a 50% improvement or more would be needed to achieve benchmark levels.
Real benefits could be had
Ms. Davis and her colleagues say there is no question that closing performance gaps would yield real benefits in terms of health, patient experiences, and savings. Thus, they say, up to 101,000 fewer people would die prematurely each year from causes amenable to health care; 37 million more adults would have an accessible primary care provider; 70 million more adults would receive all recommended preventive care; Medicare could save at least $12 billion a year by reducing hospital readmissions or reducing hospitalizations for preventable conditions; reducing health insurance administrative costs to the average level of countries with mixed private/public insurance systems would free up $51 billion or more than half the cost of providing comprehensive coverage to all the uninsured in the United States, and reaching benchmarks of the best countries would save an estimated $102 billion per year.
One of the key policy implications from the scorecard findings, the authors say, is that improvement comes when attention is focused on a particular problem. All of the quality indicators showing significant improvement have been targets of national and collaborative efforts to improve, informed by data with measurable benchmarks and indicators reached by consensus.
Conversely, the researchers found there was a failure to improve in areas such as mental health care, primary care, hospital readmission rates, or adverse drug events for which focused efforts to assess and improve at the community or facility level are lacking.
Further, they say, the continued failure to adopt interoperable health information technology makes it difficult to generate the information necessary to document performance and monitor improvement efforts.
Another important finding is that it is possible to prevent hospitalizations or rehospitalizations with better primary care, discharge planning, and follow-up carean integrated, systems approach to care. But current payment incentives for hospitals, physicians, and nursing homes don't support coordination of care or efficient use of expensive, specialized care. The report also found that information fails to slow with patients across care sites due to lack of health information technology and information exchange systems. Such inefficiencies, the researchers say, require innovative payment policies as well as care delivery approaches to improve outcomes for patients and use resources more efficiently.
Target multiple sources
Ms. Davis says that "aiming higher and moving on a more positive path will require strategies targeting the multiple sources of poor health system performance. These strategies include:
1) universal and well-designed coverage that ensures affordable access and continuity of care, with low administrative costs;
2) incentives aligned to promote higher-quality and more efficient care;
3) care that is designed and organized around the patient, not providers or insurers;
4) widespread implementation of health information technology and information exchange;
5) explicit national goals to meet and exceed benchmarks and monitor performance; and
6) national policies that promote private-public collaboration and high performance."
Ms. Davis tells State Health Watch she finds it "shocking" that only half of U.S. adults are up-to-date with recommended preventive care. The problem, she says, is that many people don't have a true medical home, a medical office that is available to them every hour of the day and night and has monitoring and reminder systems to ensure that patients get the care they need on time.
"We find that many people end up going to hospital emergency rooms because it's hard for them to get care on weekends and at night," she says. "One survey showed that 40% of physicians don't have any plan for providing after-hours care. Primary care should help manage chronic conditions. Medical offices need registries of patients with hypertension, diabetes, and other chronic conditions so they can regularly follow them and be sure they are getting the care they need."
U.S. physicians are far behind those in other countries in making use of electronic medical records, Ms. Davis says. This is partly because the U.S. government still has not set clear standards for using such electronic records. In other countries, she says, the government has helped set up needed and useful patient information exchange networks.
Because access to care is such a problem, and often is dependent on coverage, Ms. Davis says anything that states or the federal government could do to improve coverage would help. She also says people should be required as part of their coverage to designate their regular source of care and there should be some expectations made of the services a health care office that is a medical home should provide.
Because financial incentives are not always properly aligned, Ms. Davis suggests that Medicaid be revamped to reward doctors who do a good job in primary care and care management. She suggests that insurers and payers publish benchmark information and then reward doctors who perform well against the benchmarks.
Improvements will come
Ms. Davis says 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 scorecard that lives up to the best of what is possible with American ingenuity and the considerable resources invested in our health sector."
Asked for her projections for the future, Ms. Davis tells SHW she believes the nation will tackle the issue of health insurance coverage. "The lack of coverage is too serious and too detrimental not to be addressed," she says. She expects that coverage expansion will come through a mix of public and private programs, perhaps looking to the Commonwealth Fund's recent "Building Blocks" proposal as a way of expanding coverage.
She also sees much more adoption of health information technology and says the real question is whether the pace of adoption can be accelerated.
"I think we'll move away from a fee-for-service payment system to one in which we reward high quality and have more bundled fees," Ms. Davis predicts.
"Continued deterioration in the health care system and a recognition that we are not getting value for what we spend will force change," she says. "It's clear that we know what to do. The question is whether we will move forward and do it."
Download the report at www.commonwealthfund.org/usr_doc/Why_Not_the_Best_national_scorecard_2008.pdf?section=4039. Contact Ms. Davis and the other researchers at (212) 606-3800.
The Commonwealth Fund's 2008 update to its initial National Scorecard on U.S. Health System Performance, issued in 2006, contains a sobering assessment that health care in this country typically falls far short of what is achievable.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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