US Healthcare System In Comparison

Dear Friends and Colleagues;

A recent article published in Health Affairs (http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w457/DC1) focuses on the US Healthcare System performance as it compares to other nations in the world.

I can imagine that some of you may not like the findings of this study, but we need and we should proactively address these issue and not wait for others (i.e. the government) to resolve those problems:

According to the authors the United States has many of the world’s best-equipped hospitals and most highly specialized physicians. At 16 percent of gross domestic product (GDP), U.S. health spending is double the median of industrialized countries and since 2000 has been growing more rapidly than before.Yet the United States is the only major industrialized country that fails to guarantee universal health insurance; coverage in this country is deteriorating, leaving millions without affordable access to care.The U.S. health system also is not the best on quality of care, nor is it a leader in health information technology (IT).

To delineate the status of U.S. health care and opportunities to improve, the authors have developed a national scorecard spanning health outcomes, quality, access, efficiency, and equity in one report.

Thus, the scorecard, which was designed to assess and monitor all key dimensions of performance in relationship to benchmarks and over time, provides a unique whole-system view. Benchmarks and targets for improvement are based primarily on levels achieved internationally or within the United States.

Study Methods:

With guidance from the Commonwealth Fund Commission on a High Performance Health System and input from leading experts, the scorecard includes key indicators drawn from efforts of public, professional, and other national entities plus new analyzes. Criteria for indicator selection focused on sentinel or whole-system measures that capture key areas where improvement could make a major difference for the public, where information is available from international or national databases, and where the potential exists for time-trend analyzes. In total, the scorecard includes thirty-seven scored indicators, many of which are composites. The indicator set includes thirteen from new data analyzes and composites developed for the scorecard; the remainder represent an array from past research and ongoing efforts to track quality performance.

Some of the highlights of the report are as follows:

OUTCOME MEASURES:

"Long, Healthy and Productive Lives"

An indicator of mortality from conditions amenable to health care, widely used in Europe, is deaths before age seventy-five from conditions that are at least partially preventable or modifiable with timely and effective health care. The United States ranked fifteenth out of nineteen countries on this indicator as of 1998, with a death rate more than 40 percent higher than the benchmark, which is the average of the three best countries (France, Japan, and Spain).

The United States ranked last on infant mortality out of twenty-three industrialized countries as of 2002, with rates more than double the average of the three leading countries (Iceland, Japan, and Finland). The United States tied for last with Portugal, Ireland, Denmark, and the Czech Republic on healthy life expectancy at age sixty. The U.S. ranking reflects shorter life expectancy and more years of life with poor health and disability.

Within the United States, there is wide variation across states on the percentage of working-age adults with health-related limits on their ability to work or do other activities and in the percentage of children missing eleven or more days from school because of illness or injury.

Quality of Care:

High-quality care means care that is “right” (effective), well-coordinated, safe, patient-centered, and timely. On multiple quality indicators there are substantial spreads between the top and bottom groups of hospitals, health plans, or states

Based on patients’ reports, just about half of adults receive all recommended clinical screening tests and preventive care according to U.S. national guidelines.Only half of adults and 59 percent of children needing mental health care receive treatment. Rates are only 15 percent better for high-income adults. In general, the scorecard results confirm those of a medical-record-review study that found low rates of receipt of recommended care for adults.

For children, receipt of basic vaccines and annual preventive medical and dental care varies greatly across states.

As a result, national averages are well below the benchmark top 10 percent of states. National average rates of chronic disease control—using diabetes and hypertension as key indicators—also fall well below benchmark rates achieved by the top decile of health plans. Even within managed care plans, there is a wide spread in performance.

Hospitals vary in their provision of care according to basic clinical guidelines for heart attacks, congestive heart failure (CHF), and pneumonia. Although top-performing hospitals reached 100 percent adherence, hospitals delivered recommended care only 84 percent of the time on a composite measure of ten clinical processes that are reported to Medicare in exchange for full payment updates.

Across the United States, patients discharged from the hospital with CHF receive written discharge instructions only 50 percent of the time, on average, and there is an eighty-percentage-point spread between the top and bottom 10 percent of hospitals and a forty-percentage-point spread between the top and bottom 10 percent of states (64 percent versus 26 percent, data not shown). Patients hospitalized for mental health conditions often do not receive follow-up care within thirty days of discharge. On both CHF and mental illness indicators, there is a gap of twenty to thirty percentage points between national averages and rates achieved by the top group of hospitals or health plans. These shortcomings put patients at risk for complications and readmissions and raise the cost of care.

Visits to doctors for adverse drug events vary greatly across regions and have increased in the past five years. The percentage of elderly people prescribed one of thirty-three drugs listed as inappropriate has edged up since 2000, as has the percentage of children prescribed antibiotics for sore throats since 1998.

Among nursing home residents, inadequate care can result in pressure sores with risks of serious complications.

It would take a 33 percent reduction in national pressure sore rates to reach the average level achieved by the top five states.

Hospital-standardized mortality ratios provide an overall indicator of hospital safety and quality used internationally and in the United States to target improvement. Based on 2000–2002 mortality rates for Medicare beneficiaries, there is a thirty-three-percentage-point spread between the risk-adjusted mortality ratios achieved in the best 10 percent of hospitals (lowest rate) and the bottom 10 percent. If hospitals with observed mortality rates that are higher than expected brought deaths down to the levels that were expected given their patient mix, the improvement would translate into an estimated 17,000–21,000 fewer deaths per year. Reducing mortality rates to the level achieved by the top-performing group of hospitals (lowest 10 percent) would more than triple the number of lives saved.

Studies repeatedly find that the single most important determinant of whether patients obtain essential health care is having health insurance.

Affordability of Care

With insurance premiums rising at higher rates than wages and consumer cost sharing up sharply, the affordability of insurance and care is of increasing concern to middle- and low-income families and employers.

The scorecard includes two indicators for universal participation: adequate insurance and receipt of needed care. The insurance indicator tracks the percentage of adults who are adequately insured all year. Inadequate protection or being underinsured is defined as having expenses that exceed 10 percent of family income (5 percent for those with incomes below 200 percent of the federal poverty level) or being exposed to deductibles that alone constitute 5 percent of income. As of 2003, sixteen million U.S. adults (ages 19–64) were underinsured, and sixty-one million adults (35 percent) were either uninsured or underinsured. In 2004, 40 percent of U.S. adults reported that they went without care because of costs during the year, a rate four times higher than in the United Kingdom, the benchmark country.

Only 58 percent of the nonelderly population lives in a state where employer insurance premiums average less than 15 percent of this population’s median household income. One-third of nonelderly adults report having problems with medical bills, collection agencies, or medical debt. High out-of-pocket and premium costs compared to income affect 17 percent of all nonelderly families. Time trends on all three indicators have been moving toward less affordability.

Efficiency:

An efficient care system seeks to maximize the quality of care and outcomes for the resources committed to health care, and it focuses on strategies that produce greater net value over time. The scorecard includes five clusters of efficiency indicators: evidence of overuse, inappropriate care, duplication, or waste; inefficient use of resources associated with poor access; regional variations in quality and costs; percentage of health expenditures on insurance administrative costs; and lack of information systems that foster efficiency. The findings point to opportunities to gain net value, including saving lives and reducing costs if the nation could move toward rates achieved by the highest-performing regions

U.S. patients often report that records or test results were not available at the time of their appointment and that doctors unnecessarily repeated tests. In a six-nation survey, U.S. rates are two to three times the lowest-rate benchmark countries on both indicators.

Within the United States, the NCQA has begun tracking potential overuse or inappropriate care by expanding Health Plan Employer Data and Information Set (HEDIS) measures to include ordering of imaging tests for patients with lower back pain with no apparent risk factors. Among both private and Medicaid plans, the average rates of potentially inappropriate testing are 50 percent higher than are those for the lowest 10 percent of health plans.

Lack of availability of physicians when a patient is sick or in need of after-hours care can result in a visit to a hospital ER. Based on a cross-national survey in six nations asking patients about ER use for conditions that could have been seen by a regular doctor if available, it would require nearly an 80 percent reduction in U.S. rates to reach rates achieved by Germany and New Zealand, the benchmark countries. Within the United States, ER use rates for conditions that could have been cared for by regular doctors were significantly higher for uninsured, low-income, and minority patients.

Equity:

National policy statements, including the Healthy People 2010 targets, have made reducing and eliminating disparities in U.S. health care a top priority. The scorecard documents major inequities in health, quality, access, and efficiency dimensions. Disparities are widest in the paired contrasts by income or insurance, with an average 34 percent gap between uninsured and insured populations and a 38 percent gap between low-income and high-income populations. On multiple indicators, it would require a 50 percent or greater improvement in rates among the low-income or uninsured to equal the experience of high-income or insured groups. Living in low-income communities also is associated with disparities. Cancer statistics demonstrate systematically lower five-year survival for whites, blacks, and Hispanics in high-poverty geographic areas.

Perspective:

The overall picture that emerges from the scorecard is one of missed opportunities and room for improvement. Despite high expenditures, the United States lags behind other countries on indicators of mortality and healthy life expectancy. Within the United States, there is often a substantial spread between the top and bottom groups of states, hospitals, or health plans as well as wide gaps between the national average and top rates. As a result, the U.S. performance relative to benchmarks averages near 50 for efficiency to 70 for healthy lives, quality, access, and equity, for an overall average score of 66 across the main domains of performance On multiple indicators, the United States would need to improve its performance by 50 percent or more to reach benchmark countries, regions, states, hospitals, health plans, or targets.

Policies are needed that address the interaction of access, quality, and cost and take a coherent, whole-system view rather than a fragmented approach to change. Universal coverage and participation are essential to improving health care quality and cost performance. High and rising rates of the population that is under- and uninsured destabilize the delivery system, fuel inefficient use of resources, and put families and the nation at risk of losing ground on past gains in health and workforce productivity.

Lack of access to primary care, poor quality in hospitals and nursing homes or during transitions, and inadequate information systems contribute to duplicate efforts, inefficient use of specialized care, and higher rates of hospital admission and readmission, which raise the costs of care and lead to poorer outcomes.

There is evidence that quality and efficiency can be improved together. Savings can be generated from more efficient use of costly resources, producing the same or better quality at lower resource cost. The challenge is finding systematic ways to achieve net gains and rechannel the savings into investments to improve coverage and the capacity to innovate. The critical importance of improving coordination of care emerges across multiple indicators. Policies that facilitate and promote more-connected care, linking medical care providers and information in more integrated care systems, will be essential for productivity, efficiency, and quality gains.



U.S. Health System Performance:
A National Scorecard

The United States would have to improve its performance
on key indicators by 50 percent or more to reach benchmark rates.


by Cathy Schoen, Karen Davis, Sabrina K. H. How,
and Stephen C. Schoenbaum


ABSTRACT:

This paper presents the findings of a new scorecard designed to assess and monitor multiple domains of U.S. health system performance. The scorecard uses national and international data to identify performance benchmarks and calculates simple ratio scores comparing U.S averages to benchmarks. Average ratio scores range from 51 to 71 across domains of health outcomes, quality, access, equity, and efficiency. The overall picture that emerges from the scorecard is one of missed opportunities and room for improvement. The findings underscore the importance of policies that take a coherent, whole-system approach to change and address the interaction of access, quality, and cost. [Health Affairs 25 (2006): w457–w475; 10.1377/hlthaff.25.w457]