For the 16 percent of its gross domestic product that the United States spends on health care — double the median for industrialized nations — the U.S. gets some of the world´s best hospitals and most highly specialized physicians. Despite spending all that money, however, the U.S. remains the only industrialized country in the world that does not guarantee universal coverage. It is not a leader in the adoption of health information technology, and it achieves neither the best outcomes nor the best quality of care when compared to other nations. Wide variations within the United States in quality, access, and costs pull national averages down to well below benchmarks achieved by top-performing states, hospitals, or other providers.
So report Cathy Schoen and her colleagues at the Commonwealth Fund in a new article published today on the Health Affairs Web site. Schoen´s article describes the scores earned by the nation´s health care system on a new national scorecard developed by Commonwealth. 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," the authors explain. Development of the scorecard, which will be issued annually, was spearheaded by the Commonwealth Fund Commission on a High Performance Health System, led by James Mongan, M.D., president and CEO of Partners Healthcare System in Boston.
"The overall picture that emerges from the scorecard is one of missed opportunities and room for improvement," say Schoen, a senior vice president for research and evaluation at Commonwealth, and coauthors. The United States´ total average score across all categories was 66 out of a possible 100, and "on multiple indicators, the United States would need to improve its performance by 50 percent or more" to reach the levels attained by top performers. In addition, within the U.S., the spread between top and bottom performers was often large. As a result, even moving below-average areas up to average would represent significant improvement.
The Commonwealth scorecard contains thirty-seven scored indicators, although many of these are composites. The indicators, a mix of existing and new measures, are grouped into five broad "domains": health outcomes, quality, access, efficiency, and equity. A score of 100 on a given indicator represents not perfection but rather benchmarks set by top-performing countries or the top 10 percent of U.S. states, hospitals, health plans, or other providers.
Some notable results from the scorecard include the following:
— Health Outcomes. (Total U.S. score: 69) On a measure of "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 in 1998.
— Quality. (Total U.S. score: 71) Barely half of adults receive all recommended clinical screening tests and preventive care according to guidelines. Only half of adults and just under 60 percent of children receive needed mental health care. In addition, almost one-third of adults and more than half of children do not have a primary care "medical home" — a physician "who is available and serves as a central source of primary care and referral."
— Access. (Total U.S. score: 67) Four out of ten U.S. adults reported that they went without care because of costs during 2004 — a rate four times higher than in the United Kingdom, the benchmark country.
— Efficiency. (Total U.S. score: 51) Rates of hospital readmission vary widely across geographic areas: Rates in the highest hospital regions were more than 50 percent higher than in the lowest 10 percent of regions. Additionally, in a six-nation survey, U.S. patients reported that records or test results were not available at the time of their appointment, and that doctors unnecessarily repeated tests, at rates two to three times higher than patients in the lowest-rate benchmark countries.
— Equity. (Total U.S. score: 71) "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."
Schoen and coauthors write, "This first edition of the scorecard offers a starting point for national discussion." Beginning that discussion, the authors interpret the scorecard´s results as evidence of the need for policies "that address the interaction of access, quality, and cost and take a coherent whole-system view rather than a fragmented approach to change." The Commonwealth researchers also call for the discussion to be better informed through research: "In a $2 trillion health care sector, the federal government spends only an estimated $1.5 billion on health systems research — less than $1 for every $1,000 of national health spending," they point out.