National health care scorecard: United States scores 64 out of 100

At the same time, the scorecard highlights some bright spots for the U.S., with notable gains in quality of care in areas that have been the focus of public reporting or collaborative improvement initiatives. For example, 50 percent of adults with high blood pressure had it under control in 2007-2008, compared with only 31 percent in 1999-2000. In addition, hospital quality indicators for treatment of heart attack, heart failure, and pneumonia, and prevention of surgical complications, have improved substantially across the country since hospitals began publicly reporting their quality data through a federal website.

The report, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011, measures the U.S. health care system across 42 key indicators of health care quality, access, efficiency, equity, and healthy lives. The scorecard compares U.S. average performance to rates achieved by the top 10 percent of U.S. states, regions, health plans, hospitals or other providers or top-performing countries. The 2011 score of 64 was slightly below the overall score of 67 in the first national scorecard published in 2006, and the score of 65 in the second scorecard, in 2008. The authors note that latest data in the scorecard primarily fall between 2007 and 2009, before enactment of the Affordable Care Act. They point out that provisions in the new law target areas for improvement where the U.S. falls short, particularly in access to care, affordability of care, and support for more patient-centered, coordinated care.

"If we target areas where we fall short and learn from high-performing innovators within the United States, we should see significant progress in the future," said Commonwealth Fund Commission Chair David Blumenthal, M.D., Samuel O. Thier Professor of Medicine and Professor of Health Care Policy at Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School. "The Affordable Care Act and investments in information systems offer the potential for rapid progress in areas like adoption and use of health information technology, safer care, and premature deaths from preventable complications."

The scorecard finds that the U.S. is failing to keep up with gains in health outcomes made by other countries: the U.S. ranks last out of 16 countries when it comes to deaths that could have been prevented by timely and effective medical care. If the U.S could do as well as the leading country, as many as 91,000 fewer people would die prematurely every year.

Quality Initiatives Showing Promise

According to the scorecard, public reporting of quality data on federal Web sites and collaborative initiatives, like the Advancing Excellence nursing home improvement campaign and Premier hospital quality initiatives, have resulted in substantial and rapid improvements on some quality indicators. For example:

• The proportion of home health care patients who gained improved mobility grew from 37 percent to 47 percent from 2004 to 2009.
• 96 percent of hospitals reported providing the right care to prevent surgical complications in 2009, up from 71 in 2004.

Despite these improvements, quality of care still varies widely across the country. For example, despite a 13 percent drop in hospital admissions for heart failure and pediatric asthma from 2004 to 2007, rates vary twofold to fourfold across states.

"This scorecard illustrates that focused efforts to change the health care system for the better are working and are worth our investment," said Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement, and a Commonwealth Fund Board and Commission member. "Yet, the U.S. still spends up to twice as much on health care as other high-income countries, but too often fails to deliver what people need -- timely access to high quality, efficient health care. The places in the U.S. and around the world that set the benchmarks prove that it is possible to do better."

Failing To Improve

Despite some quality improvements, the scorecard finds that in many areas U.S. health system performance has either failed to improve, or declined over time.

Steep Decline in Access and Affordability

Access to health care and health care affordability stand out for how quickly and significantly they deteriorated. By 2010, 81 million adults -- 44 percent of all adults under age 65 -- were either underinsured or uninsured at some point during the year -- up from 61 million in 2003. For those with insurance, premiums rose far faster than incomes. In 2003, a majority of people (57 percent) lived in a state where health insurance premiums averaged less than 15 percent of average (median) incomes. By 2009, only four percent of the population lived in such states. In addition, by 2010, 40 percent of working-age adults had medical debt or faced problems paying medical bills up from 34 percent in 2005.

Broad Evidence of Inefficient Care

The U.S. also does particularly poorly on measures of health system efficiency, scoring only 53 out of a possible 100. This area of the scorecard includes such issues as evidence of duplicative services, high rates of hospital readmissions, relatively low use of electronic information systems, and high administrative costs. This low score translates into significant costs to the health care system. For example, the scorecard finds that the U.S. could save $55 billion a year if it could lower insurance administrative costs to the average of administrative costs in other countries with mixed public-private insurance systems.

Other areas of concern include:

• Primary care and preventive care: Forty-four percent of adults report that they didn't have an accessible primary care provider in 2008, and only half of adults received all recommended preventive care -- which is on par with what was reported in the 2006 Scorecard.
• Childhood obesity: Childhood obesity rates are high, with about one-third (32%) of children ages 10 to 17 overweight or obese, ranging from one-quarter to 39 percent between the top and bottom five states.
• Infant mortality: The average U.S. infant mortality rate is more than 35 percent higher than the rates achieved in the best states, and rates in even the best states are twice as high as those in other countries.
• Safe care: One-quarter of elderly Medicare beneficiaries were prescribed a potentially inappropriate drug.
• Rehospitalizations: Rehospitalization rates failed to improve and varied widely, with 20 percent of Medicare patients hospitalized for certain conditions or procedures readmitted within 30 days in both 2003 and 2009. Rates in the highest-rate regions were 50 percent higher than in the lowest-rate regions.

Potential for Improvement

The scorecard identifies pockets of high performance which illustrate the potential for the nation if others could learn from these high performers. Improvements would add up to significant gains in lives and dollars saved. For example, if the entire nation could do as well as the top performers:

• Thirty-eight million more adults would have a primary care doctor and 66 million more would receive all recommended preventive care.
• Reducing health insurance administrative costs to the average level achieved in countries with mixed private-public insurance systems, like the U.S., would save $55 billion a year. Achieving benchmarks of the best countries would save an estimated $114 billion a year.
• Up to 91,000 fewer people would die before age 75 each year of conditions amenable to health care, include screenable cancers, diabetes, and infections.

Moving Forward: The Affordable Care Act

The Affordable Care Act will lay the groundwork for wider reforms by providing all families access to affordable and comprehensive health insurance regardless of where they live. The report notes that access to insurance is "the essential foundation for improvement" as access, health care quality, and efficiency are interrelated. In addition, the Affordable Care Act includes reforms that seek to strengthen primary care, improve care coordination, invest in prevention, and to ensure access to high quality care that focuses on improving health.

"Health care reform is already beginning to improve health system performance by expanding access to care, reducing administrative costs in health insurance, and piloting projects that could improve health care quality and achieve savings," said Commonwealth Fund President Karen Davis. "This year's scorecard makes it clear that changes in the Affordable Care Act designed to reduce waste, cut costs and help people afford the care they need are on target. The health and future economic security of the country depend on moving forward with these crucial reforms."

Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011, is authored by Commonwealth Fund researchers Douglas McCarthy, Sabrina K. How, Ashley-Kay Fryer, David C. Radley, and Cathy Schoen.