Diagnostics & Imaging Week Associate

The U.S. healthcare system received a failing grade, and will continue to decline unless some drastic changes are made, according to a report card-style assessment issued last week by the Commonwealth Fund (New York).

The new report, from The Commonwealth Fund Commission on a High Performance Health System, paints a disturbing picture – that of a healthcare system in the wealthiest country in the world failing to achieve top marks in any single assessed healthcare category. In fact, the report shows that the U.S. healthcare system is falling into the classic underachiever category, especially given the country's current level of investment in healthcare.

The U.S. scored an average of 66 out of a possible 100 across 37 national indicators of health outcomes, quality, access, equity, and efficiency. The scorecard findings show that if the U.S. improved performance in key areas, the nation could save an estimated 100,000 to 150,000 lives and $50 billion to $100 billion annually.

While other organizations have used a grading system to evaluate the healthcare system, according to Mary Mahon, senior public information office at the Commonwealth Fund, this is the first scorecard to assess the country's healthcare system across all key domains of care and to compare national averages to benchmarks of achieved performance. It is also the first to offer international comparisons as well as comparisons within the U.S. by state and region.

"There are many report cards and rankings that different organizations do," Mahon told Diagnostics & Imaging Week, "but what's different and unique about this one is that it looks at all of these aspects of the health system simultaneously. Most of the report cards that you see will look at only one aspect of the healthcare system."

The report accompanies a Health Affairs web exclusive article released today, "U.S. Health System Performance: A National Scorecard," by Commonwealth Fund Senior Vice President Cathy Schoen and colleagues. "An overarching theme of the scorecard is the extent to which lack of healthcare coverage and gaps in access to care drive up costs and pull down quality of care in the U.S.," said Schoen. "The vital signs of the healthcare system are going in the wrong direction — costs are going up and the percentage of people with adequate insurance is going down. We urgently need to change course."

The U.S. ranks poorly at the beginning and end of life, according to the report, "Why Not the Best? Results from a National Scorecard on U.S. Health System Performance."

One surprising finding was a score of 69 in the category of "long, healthy, and productive lives." The report found that the U.S. is one-third worse than the best country (France at 75 deaths per 100,000 population) on mortality from conditions "amenable to healthcare" – that is, deaths that could have easily been prevented with timely and effective care. In 1998, the U.S. ranked 15^th out of 19 countries on this indicator, with 115 deaths per 100,000 population. If mortality were reduced to the benchmark level, the improvement would translate into 88,000 fewer deaths per year.

The U.S. ranks at the bottom among industrialized countries on healthy life expectancy at birth or age 60, and last out of 23 listed high-income industrialized countries on infant mortality (7 deaths per 1,000 live births). This last figure is particularly disturbing for a so-called leading industrialized nation, the authors say.

In addition to scoring poorly on indicators compared to other countries, the report says that the U.S. national averages vary greatly from state-to-state, region-to-region and across hospitals and health plans, suggesting the need for a top-down look at improving uniformity of healthcare in the U.S. While the top tier of the system achieves excellence in some areas, the report found that the uneven performance across the country indicates a need for major improvement. Rates at the bottom of the distribution are often well below the leaders and the national average.

For example, for readmissions to hospitals, there is wide variation between the best and worst 10% of U.S. regions: rates in the worst 10% are more than 50% higher than the lowest 10% of regions. The extent to which chronic care is managed well also varies widely among health plans.

"What this report tells us is that there are many pockets of excellence in healthcare in this country, but overall we are performing far below our national potential," said James Mongan, MD, chairman of the 18-member commission and CEO of Partners HealthCare (Boston), a corporation overseeing the affiliation of Brigham and Women's Hospital, the Massachusetts General Hospital, and the North Shore Medical Center. "Our purpose in issuing this scorecard is to bring attention to opportunities to improve, with benchmarks to motivate change. This is an important first step towards moving to a system that is truly high performing."

The scorecard also reveals large gaps between national averages and benchmarks of higher performance across an array of quality, access, efficiency and equity indicators — from the percentage of adults receiving recommended screening and preventive care, to deaths in hospitals, to the percent of national health expenditures that go to insurance administrative costs.

The scorecard shows that the U.S. falls far short on universal health insurance coverage, as well as measures of preventive and primary care, undermining health outcomes and raising the cost of care. Access indicators in the scorecard reveal high rates of medical debt in the U.S. and large numbers of adults who are uninsured and underinsured — insured but not well protected from high healthcare costs.

The commission report presents a case for change in the way U.S. healthcare is financed, organized, and delivered. A better-coordinated system of care that is accessible to all would save lives and billions of dollars, according to the scorecard.

The report notes that efficiency scores were generally low in the U.S., pulled down by indicators of over-use/waste, poor access, and cost/quality variation.

This overall low efficiency score also reflects the fact that the U.S. is far behind other countries in use of electronic medical records (EMRs) and has much higher insurance administrative costs. The report noted that only 17% of U.S. doctors used EMRs compared to 80% in the top three countries as of 2000/2001, and recent U.S. studies indicate slow dispersion, despite President George Bush's call for increased use of EMRs.

U.S. insurance administrative costs as a share of total health spending are more than three times the rates of the best performing countries and well above the next highest country rate. The U.S. spends 7.3% of national health expenditures on health administration and insurance, compared to about 2% in France and Japan and 5.6% in Germany, the report says.

The Commonwealth Fund Commission on a High Performance Health System, formed in April 2005, says its goal is to seek opportunities to change the delivery and financing of healthcare and to identify policies and practices that would lead to those improvements. It also is exploring mechanisms for financing improved health insurance coverage and investment in the nation's capacity for quality improvement, including reinvesting savings from efficiency gains.

While Mahon noted that this report didn't come up with specific solutions to many of the problems being experienced by the U.S .healthcare system, she told MDD that the commission "will be issuing reports over the next several years making some recommendations for strategies to achieve the goals and benchmarks that we've outlined in this [current] report." She said the commission hopes to have that follow-on report available by early 2007.

The current report, she said "was more of a diagnosis of the problems" in the U.S. healthcare field." Citing some of the successes of other countries that were discussed in the report, she characterized as "achievable" all the goals mentioned.

The full report is available at www.cmwf.org.