Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011

As the United States implements national health care reforms, it is instructive to take stock of how well our health system is able to provide access to high-quality, efficiently delivered care. Evidence from the new 2011 edition of the National Scorecard on U.S. Health System Performance shows substantial erosion in access to such care in the period leading up to health reform, along with rising costs that are stressing families, businesses, and all levels of government. Variations in health care delivery, moreover, persist throughout the U.S., as opportunities are routinely missed to prevent disease, disability, hospitalization, and mortality. At the same time, the Scorecard finds notable gains in quality of care in those areas where the nation has made a commitment to accountability and undertaken targeted improvement efforts.

Based on the Scorecard's 42 indicators of health system performance, the U.S. earned an overall score of 64 out of a possible 100 when comparing national averages with benchmarks of best performance achieved internationally and within the U.S. Although the Scorecard draws on the latest available data, primarily from the period 2007 to 2009, the results do not fully reflect the effects of the recent economic recession on access to and use of care. The overall performance on the indicators failed to improve relative to benchmarks since the first National Scorecard was issued in 2006, or since the last update in 2008. Benchmarks, however, improved in many cases, raising the bar on what is attainable.

Some good news can be found in an exception to the overall pattern of U.S. performance: rapid progress on quality metrics that have been the focus of national initiatives and public reporting efforts. Hospitals, nursing homes, and home health care agencies are showing marked improvement in patient treatment and outcomes for which data are collected and reported nationally on federal Web sites and as part of improvement campaigns. There has also been significant improvement in the control of high blood pressure, a measure that is publicly reported by health plans; increasingly, physician groups are being rewarded for improving their treatment of this and other chronic conditions. Better management of chronic diseases also has likely contributed to reductions in rates of avoidable hospitalizations for certain conditions, though rates continue to vary substantially across the country.

Of great concern, access to health care significantly eroded since 2006. As of 2010, more than 81 million working-age adults—44 percent of those ages 19 to 64—were uninsured during the year or underinsured, up from 61 million (35%) in 2003. Further, the U.S. failed to keep pace with gains in health outcomes achieved by the leading countries. The U.S. ranks last out of 16 industrialized countries on a measure of mortality amenable to medical care (deaths that might have been prevented with timely and effective care), with premature death rates that are 68 percent higher than in the best-performing countries. As many as 91,000 fewer people would die prematurely if the U.S. could achieve the leading country rate.

Sharply rising costs are putting both access and budgets at risk. Health care spending per person in the U.S. is double that in several other major industrialized countries, and costs in the U.S. continue to rise faster than income. We are headed toward spending $1 of every $5 of national income on health care. We should expect a better return on this investment.

Performance on indicators of health system efficiency remains especially low, with the U.S. scoring 53 out of 100 on measures that gauge the level of inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. Lowering insurance administrative costs to benchmark country rates could alone save up to $114 billion a year, or $55 billion if such costs were lowered to the level in countries with a mixed private–public insurance system, like the U.S. has.

The lack of improvement on many health system indicators—such as preventive care, adults and children with strong primary care connections, and hospital readmissions—likely stems from the nation's weak primary care foundation and from inadequate care coordination and teamwork both across sites of care and between providers. These gaps highlight the need for a whole-system approach, in which performance is measured and providers are held accountable for performance across the continuum of care.

To produce greater value from the resources the nation devotes to health care, action is urgently needed to improve access to care and the performance of the care delivery system. Provisions in the Affordable Care Act target many of the gaps identified by the National Scorecard, particularly access, affordability, and support for innovations to make care more patient-centered and coordinated. Scorecard indicators in each of these areas provide a baseline for monitoring performance over time and assessing whether these reforms and others being pursued in the public and private sectors succeed in closing performance gaps.

THE NATIONAL SCORECARD

The 2011 National Scorecard comprises an expanded set of 42 indicators within five dimensions of health system performance: healthy lives, quality, access, efficiency, and equity. The Scorecard compares U.S. average performance with benchmarks drawn from the top 10 percent of U.S. states, regions, health plans, and hospitals or other providers, as well as from the top-performing countries. If average U.S. performance came close to the top rates achieved here at home or abroad, then average scores would approach the maximum of 100.

The 2011 Scorecard finds that the U.S. as a whole scores only 64, compared with 67 in 2006 and 65 in 2008—well below the benchmarks. Average scores on each of the five dimensions of performance range from a low of 53 for efficiency to a high of 75 for quality of care. Exhibit 2 lists the 42 indicators and summarizes benchmarks and ratio scores across the five dimensions for the latest period (historical data can be found in Appendices A2 to A6).

Performance compared with benchmarks improved on less than half of the indicators for which data are available to assess trends since the first Scorecard. National rates for three of five (58%) Scorecard indicators worsened or failed to substantially improve. On a few indicators, such as mortality amenable to health care (described above), the score declined because benchmark performance improved more than the national average.

As observed in the 2006 and 2008 National Scorecards, the bottom-performing group of hospitals, health plans, or geographic regions typically performs well below average, with as much as a fourfold spread between the top and bottom rates. Across all measures, a 40 percent improvement or more would be required in U.S. national rates to achieve benchmark levels of performance.

HIGHLIGHTS OF THE 2011 NATIONAL SCORECARD

There have been encouraging improvements on several key performance indicators, as well as a number of instances where performance declined or failed to keep pace with the performance of leading nations, delivery systems, states, or regions.

Indicators That Show Promising Improvements

• Information systems. The proportion of primary care physician practices that use electronic medical record (EMR) systems increased from 17 percent to 46 percent from 2000 to 2009. Still, the U.S. lags far behind the leading countries, where nearly all physicians now use EMRs. Financial incentives for the adoption and "meaningful use" of EMRs, enacted as part of the federal economic stimulus legislation, should promote greater uptake of this technology.
• Care for chronic conditions. Control of high blood pressure improved from 31 percent in 1999–2000 to 50 percent in 2007–2008 among national samples of adults with hypertension, a likely result of stepped-up awareness campaigns and preventive treatment targeting heart disease and stroke. Nevertheless, there continues to be room for improvement, as the benchmark rate of control attained by the best-performing health plans is 75 percent.
• Effective hospital care. Hospitals provided proven treatments to prevent surgical complications 96 percent of the time in 2009, an increase from 71 percent in 2004. Adherence to treatment standards for heart attack, heart failure, and pneumonia rose from 84 percent to 96 percent. This rapid improvement came on the heels of a consensus reached on quality measures and the federal policy linking Medicare payment updates to hospitals' agreement to publicly report their results. Still, a significant gap remains between leading and lagging hospitals.
• Preventable hospitalizations. Rates of hospitalizations for some ambulatory care–sensitive conditions declined. For example, admission rates for heart failure and pediatric asthma each dropped by 13 percent from 2004 to 2007, a possible reflection of improved disease management. But rates continued to vary twofold to fourfold across hospital referral regions and states.
• Quality of postacute and long-term care. Rates of pressure sores among short-stay nursing home residents fell from 19 percent to 14 percent from 2004 to 2008, with a similar decline among long-stay residents. The proportion of home health care patients who gained improved mobility grew from 37 percent to 47 percent from 2004 to 2009. These results likely reflect the influence of public reporting and collaborative efforts, such as the national Advancing Excellence in America's Nursing Homes campaign.
• Cigarette smoking. Continuing a long-running trend, the prevalence of U.S. adults who smoked cigarettes declined from 21 percent in 2004 to 17 percent in 2010. Two leading states (Utah and California) reached or exceeded the federal government's Healthy People 2010 goal of 12 percent. Yet rates in the states with the highest smoking prevalence are twice that level, pointing to the need for wider adoption of comprehensive evidence-based tobacco control measures.
• Preventable mortality. The rate of mortality amenable to health care—deaths that might have been prevented with timely and effective care—improved 21 percent in the U.S. between 1997–98 and 2006–07 (from 120 to 96 deaths per 100,000). However, rates improved by 32 percent, on average, in 15 other industrialized nations, meaning the U.S. ranks last, with a rate 68 percent higher than the rate in the leading countries.

Indicators That Show Significant Deterioration or No Improvement

• Insurance and access. As of 2010, 81 million adults—representing 44 percent of all working-age adults—were either uninsured sometime during the year or underinsured, meaning they were insured all year but had medical bills or deductibles that were high relative to their incomes. This represents a 33 percent increase from 2003, when the total was 61 million. Rates were even higher, and increased, among lower- and middle-income adults.
• Affordable care. As insurance premiums rose faster than wages, the share of working-age adults living in a state where group health insurance premiums averaged less than 15 percent of household income dropped from 57 percent in 2003 to just 4 percent in 2009. Forty percent reported they had medical debt or problems paying medical bills in 2010, compared with 34 percent in 2005, in a likely carryover from the recession.
• Primary and preventive care. In 2008, more than two of five (44%) nonelderly adults lacked a regular primary care provider that is easy to get to and consult with by phone during office hours, and only half received a set of basic preventive services—representing little change from 2002. The vaccination rate for young children recovered in 2010 following a sharp decline caused by a vaccine shortage in 2009, yet one-quarter of children still lacked full protection against communicable diseases.
• Hospitalizations from nursing homes. From 2000 to 2008, the rehospitalization rate increased for patients who were discharged to skilled nursing facilities (from 18% to 21%), as did the hospitalization rate for long-stay nursing home residents (from 18% to 20%). This signals a need to improve both quality of care and patients' transitions from one care setting to another.
• Rehospitalizations. Average rates of hospital readmissions within 30 days of discharge for selected conditions or procedures remained high—20 percent of discharged Medicare patients in both 2003 and 2009. Rates in the highest-rate regions were 50 percent higher than those in the lowest-rate regions. The Affordable Care Act will provide incentives for lowering readmission rates.

Additional Indicators That Raise Concerns

• Infant mortality. While infant mortality modestly improved from 2002 to 2007 (from 7.0 to 6.8 deaths per 1,000 live births), the U.S. rate is still more than 35 percent higher than the rates achieved by the best individual states. In fact, rates in the best states are twice as high as those achieved in certain industrialized countries. High infant mortality is related to high rates of preterm births, which in turn are related to long-term maternal health as well as quality of pregnancy care.
• Childhood obesity. Nearly one-third (32%) of children ages 10 to 17 were overweight or obese as of 2007, with rates ranging from 24 percent to 39 percent among the top and bottom five states. Unless there is an improvement in healthy eating and weight control, obesity and related health problems are likely to rise—and could wipe out recent health gains from declining smoking rates.
• Safe care. In a sign that safety concerns extend beyond the hospital, in 2007 one-quarter of elderly Medicare beneficiaries were prescribed a drug that is potentially inappropriate for older people. Rates were twice as high in some regions of the country as in others (36% vs. 18%). Wider use of electronic systems that alert clinicians of such risks may help improve safety in the near future.
• Patient-centered, timely, coordinated care. In 2008, only 43 percent of U.S. adults with health problems were able to rapidly secure an appointment with a physician when they were sick—about half the rate in the best country. U.S. adults also were among the most likely of those in eight countries surveyed to report difficulty obtaining health care after regular office hours without going to the emergency department. And 19 percent of U.S. patients reported undergoing duplicate tests—almost five times the rate in the benchmark country.
• Disparities. Minorities and low-income or uninsured adults and children were generally more likely than their white, higher-income, or insured counterparts to wait to see a doctor when sick, to encounter delays and experience poorly coordinated care, and to have untreated dental caries, uncontrolled chronic disease, avoidable hospitalizations, and worse outcomes. And they were less likely to receive preventive care or have an accessible source of primary care.

SUMMARY AND IMPLICATIONS

Potential for Improvement
Overall, the National Scorecard on U.S. Health System Performance, 2011, finds that the United States is losing ground in the effort to ensure affordable access to health care. Although there are promising improvements on key indicators, quality of care remains uneven. The Scorecard also finds broad evidence of inefficient and inequitable care. Other advanced countries are outpacing the U.S. in providing timely access to primary care, reducing premature mortality, and extending healthy life expectancy, all while spending considerably less on health care and administration.

In contrast, improvement on key quality metrics demonstrates that significant progress is possible when the country sets specific goals and targets linked to performance metrics and accountability for results. This approach is urgently needed to improve performance across all domains and care settings. Average U.S. health system performance would have to improve by 40 percent or more to reach the benchmark levels of performance attained by leading nations, states, regions, health plans, and care providers.

The nation can learn from and apply lessons about what works in the best-performing counties, states, regions, health plans, and care systems. By doing so, the country could realize substantial benefits in terms of health, patient experiences, and financial savings. For example:

• Up to 91,000 fewer people would die prematurely each year from causes amenable to health care if the U.S. achieved the lower mortality rate of the leading country—more than two times the number of people who die in motor vehicle accidents each year.
• 38 million more adults would have an accessible primary care provider, and 66 million more adults would receive all recommended preventive care.
• According to the National Committee for Quality Assurance, improving control of diabetes and blood pressure to benchmark levels would prevent disease and reduce disease complications, saving $1.6 billion to $3.1 billion per year in medical costs.
• The Medicare program alone could potentially save more than $12 billion a year by reducing hospital readmissions, based on an analysis by the Medicare Payment Advisory Commission. Additional savings could be realized from reductions in hospitalizations among the under-65 population.
• Reducing health insurance administrative costs to the average level in countries with mixed private–public insurance systems would free up $55 billion, or more than half the cost of providing comprehensive coverage to all the uninsured in the U.S. Reaching benchmarks of the best countries would save an estimated $114 billion per year.

Many of these gaps in performance are the targets of reforms included in the Affordable Care Act and the American Recovery and Reinvestment Act to stimulate and reward more effective and efficient delivery of care. Recent estimates show that health reform legislation will reduce health care spending by $590 billion over 10 years and lower premiums by nearly $2,000 per family by slowing the annual growth rate in national health expenditures. Successful implementation of these reforms, together with community-based efforts to build on this new foundation, offer the potential for improved population health, more positive care experiences, and more affordable care.

Aiming Higher to Achieve the Potential of Reform

Access to care is the essential foundation for improvement. Access to care, health care quality, and efficiency are interrelated. By expanding insurance coverage for adults as well as children, the Affordable Care Act will for the first time ensure that coverage is accessible and affordable for families across the nation. Once reform is fully implemented, coverage rates for adults in the vast majority of states are projected to rival the high rates currently achieved by only the leading states. Coverage rates for children will also improve, as whole families have access to more-affordable insurance plans that include essential benefits. New federal survey data reveal that the early provisions of the Affordable Care Act are already having a positive impact among young adults ages 19 to 25. Approximately 1 million more young adults have become insured since health plans were required to allow young adults under age 26 to stay on or join their parents' health plan.

Better primary care and care coordination offer the potential for improved outcomes at lower costs. Investment in the nation's primary care capacity will be necessary to ensure that all Americans have round-the-clock access to care, patients with chronic illnesses receive help in managing their conditions, and health services are well coordinated. Many hospitalizations or rehospitalizations are preventable with better primary care, discharge planning, and transitional and follow-up care—all part of an integrated, systems approach to care. The Affordable Care Act has the potential to strengthen primary care, reduce high rates of readmissions, and support health care organizations that agree to be accountable for providing better care, achieving better outcomes, and lowering costs. Demonstration and pilot programs will develop and test innovative payment and care delivery approaches to improve outcomes and efficiency.

Measurement and accountability focus attention on improvement. The quality indicators that showed significant improvement in the National Scorecard have been the target of national campaigns and collaborative efforts employing benchmarks and measures developed through consensus. Conversely, there was failure to improve in those areas for which common metrics or focused efforts have been lacking. The improvements in performance that did occur demonstrate that change can take place rapidly when there is leadership and accountability. These initiatives should be emulated in other areas, such as through coordinated medical and community-level interventions to promote healthy behaviors. 

Strengthening the Nation's Capacity to Improve

Fundamental to a high-performing health care system is having ample capacity to innovate and improve. This requires:

• A skilled and motivated health care workforce, particularly in the areas of primary care and population health.
• Payment and insurance benefit designs that support system transformation and primary care medical homes, ensure providers are accountable for population-level results, and activate consumers to use the care system wisely and optimize their personal health behaviors.
• A culture of quality improvement and continuous learning in which providers seek out opportunities to improve patient safety and outcomes and are recognized and rewarded for doing so.
• Investment in public health initiatives, in research, and in generating the information necessary for evidence-based health care decisions and quality improvement.

To begin to address these needs, the Affordable Care Act makes investments in prevention and provides incentives to encourage physicians to select and maintain primary care careers. New national innovation and research centers, as well, will support the development of promising payment and health care delivery models and generate evidence on the relative effectiveness of clinical practices. And, over time, federal incentives and supports to spur the adoption and meaningful use of health information technology will expand health system capacity for monitoring performance and supporting improvement efforts.

Importance of Tracking Change and Sentinel Indicators

Moving from enactment of federal legislation to successful implementation of reforms will require action on the part of multiple stakeholders and a commitment to collaborate to improve. Looking to the future, it will be critical to track key indicators of access, quality, and cost performance over time as health care delivery systems and markets respond to new incentives. As these new initiatives unfold, it will be important to monitor progress to identify areas of the health system where adjustments or new policies are needed to achieve better performance. Monitoring activities would be strengthened by federal participation in and support for state and community efforts to create all-payer databases providing information on health services and costs across the continuum of care.

The Case for a Systems Approach to Change

The U.S. health system continues to perform suboptimally relative to what is achievable and relative to the large resources invested by the nation. The Commonwealth Fund's 2011 National Scorecard documents that there are significant human and economic costs attached to our failure to address the problems in the health care system. As rising costs put family, business, and government budgets under stress, access to care and financial protection are eroding for middle-income and low-income families alike.

Successful implementation of reforms will require stakeholders at all levels to adopt a coherent, whole-system approach in which goals and policies are coordinated to achieve the best results for the entire population. By integrating all components of the health system to ensure better access, higher quality, and greater value, we would be far more able to safeguard the health and economic security of current and future generations.