THE COMMONWEALTH FUND Why Not the Best? Results from a National Scorecard on U.S. Health System Performance September 20, 2006 Cathy Schoen Senior Vice.

THE COMMONWEALTH

FUND

Why Not the Best? Results from a National Scorecard

on U.S. Health System Performance

September 20, 2006

Cathy SchoenSenior Vice PresidentCommonwealth Fund

2

THE COMMONWEALTH

FUND

• Unique scorecard that spans health outcomes, quality, access, efficiency and equity domains of performance

• Compares U.S. national averages to benchmarks drawn from internal and international comparisons

– Benchmarks generally are rates of achieved performance

– Within the United States, top 10 percent of states or regions, hospitals, health plans or other providers

– Access indicators include target benchmarks (e.g. 100% of the population insured)

• Includes 37 scored indicators, including composites of related indicators

• Scores

– Simple ratios of U.S average to the benchmark

– Scores for each domain average indicators ratios

• Designed to track changes and provide targets for improvement

National Scorecard on U.S. Health System

SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

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• The U.S. falls far short on each of the core goals for health system performance relative to benchmarks

– The US average ratio score is 66 across health outcomes, quality, access, efficiency and equity

– There are wide gaps across key indicators on benchmarks largely drawn from achieved rates

• The consequence is needlessly lost lives, wasted health care expenditures, and lower economic productivity

– $50-$100 Billion annual savings and 100,000 to 150,000 lives

– $130 billion in potential productivity gains from insuring the uninsured (Institute of Medicine estimate)

• Given that the US spends more than any other country, we should expect to lead on access, quality and efficiency

– Benchmarks provide targets for improvement

• With cost and coverage moving in the wrong direction, action to achieve a higher performance system is of great urgency

Scorecard Overview Findings: Overall Score 66

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THE COMMONWEALTH

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Scores: Dimensions of a High Performance Health System

69

71

67

51

71

66

0 100

Long, Healthy, &Productive Lives

Quality

Access

Efficiency

Equity

OVERALL SCORE

SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

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THE COMMONWEALTH

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Mortality Amenable to Health Care

97 97 99106 107 109 109

115 115

129 130 132

7584

88 88 8881

92

0

50

100

150

Deaths per 100,000 population*

110

8490

103

119

134

Percentiles

International Variation, 1998 State Variation, 2002

* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart diseaseDATA: International: WHO mortality database from Nolte and McKee 2003; U.S. 2002 state estimates: K. Hempstead, Rutgers University using Nolte/ McKee methodology. Methods in technical appendix to Scorecard Chartpack.SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and

appropriate medical care.

LONG, HEALTHY & PRODUCTIVE LIVES

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THE COMMONWEALTH

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Receipt of Recommended Screening and Preventive Care for Adults, by Family Income and Insurance Status, 2002

31

46

52

39

48

56

49

0 50 100

Uninsured All Year

Uninsured Part Year

Insured All Year

<200% of Poverty

200-399% of Poverty

400%+ of Poverty

National

Percent of adults (ages 18+ yrs) who received all recommended screening and preventive care within a specific time frame given their age and sex*

*Recommended care includes: blood pressure, cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.Data: Columbia University analysis of 2002 Medical Expenditure Panel SurveySOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

QUALITY: RIGHT CARE

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THE COMMONWEALTH

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Diabetic Adults Who Have Blood Glucose Levels Under Fair Control, National and Managed Care Plan Type

Data: National estimate—National Health and Nutrition Examination Survey (AHRQ 2005a); Plan estimates—Health Plan Employer Data and Information Set (NCQA 2005a, 2005b).

79

89

6974

69

77

50

5864

23

0

50

100

National Private Medicare Medicaid

90th %ile Mean 10th %ile

Percent of adults with diagnosed diabetes whose HbA1c level <9.0%

5863

66 68 6967

73 76 77 78

4552 52 51 51

0

50

100

2000 2001 2002 2003 2004

Private Medicare Medicaid

Annual averagesManaged care plans (2004)(1999–2002)

7SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

QUALITY: RIGHT CARE

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THE COMMONWEALTH

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Heart Failure Patients Given Written Instructions or Educational Materials When Discharged, by Hospitals and States, 2004

50

87

9

6460

49

3326

0

50

100

NationalAverage

90th %ile 10th %ile Top 10% Top 25% Median Bottom 25% Bottom 10%

Percent of heart failure patients discharged home with written instructions or educational material*

*Discharge instructions must address: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsenData: National and hospital estimates: A. Jha and A. Epstein, Harvard University analysis from Hospital Quality Alliance national reporting system; State estimates – Retrieved from Hospital Compare www.hospitalcompare.hhs.govSOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

QUALITY: COORDINATED CARE

Hospitals States

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THE COMMONWEALTH

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Nursing Homes: Hospital Admission and Readmission RatesAmong Nursing Home Residents, by State, 2000

16

89

12

19

21

0

10

20

30

Median Beststate

10th%ile

25th%ile

75th%ile

90th%ile

Percent

12

78

10

13

16

0

10

20

30

Median Beststate

10th%ile

25th%ile

75th%ile

90th%ile

Hospitalization rates

Re-hospitalization rate (within 3 months of

nursing home admission)

Data: V. Mor, Brown University analysis of Medicare enrollment data for beneficiaries who entered a nursing home and had a Minimum Data Set assessment during 2000.

Percent

9SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

QUALITY: COORDINATED CARE

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THE COMMONWEALTH

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Hospital-Standardized Mortality Ratios, 2000-2002

8593 94 97 100 103 106 106

112118

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10

Ratio of actual to expected deaths in each decile (x 100)

Decile of Hospitals Ranked by Actual to Expected Deaths Ratios

Data: B. Jarman analysis of Medicare hospital data from 2000 - 2002 for the scorecard.SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors. Medicare national average

for 2000 = 100

QUALITY: SAFE CARE

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THE COMMONWEALTH

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7063

60

93 91

100

7974

70

61

52 49

0

50

100

Staff managed pain well* Staff responded when neededhelp**

Staff explained medicines and sideeffects***

Average Best Hospital 90th %ile Hospitals 10th %ile Hospitals

Patient-Centered Hospital Care: Staff Managed Pain, Responded When Needed Help, and Explained Medicines, by Hospitals, 2005

Percent of patients reporting “always”

*Patient’s pain was well controlled and hospital staff did everything to help with pain**Patient got help as soon as wanted after patient pressed call button and in getting to the bathroom/using bedpan***Hospital staff told patient what medicine was for and described possible side effectsData: CAHPS Hospital Survey for 254 hospitals submitting data in 2005. National CAHPS Benchmarking DatabaseSOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

QUALITY: PATIENT-CENTERED, TIMELY CARE

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THE COMMONWEALTH

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Percent of Adults Ages 18–64 Uninsured by State

Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute.

SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVTNH

MARI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

ME

DE

DC

HI

CO

GAMS

OK

NJ

SD

19%–22.9%

Less than 14%

14%–18.9%

23% or more

1999–2000 2004–2005

MA

RI

CT

VTNH

MD

NH

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THE COMMONWEALTH

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Adults Ages 19-64 Who Are Uninsured and Underinsured, By Poverty Status, 2003

65

83

32

4

19

2613

499

0%

20%

40%

60%

80%

100%

Total 200% of poverty or more Under 200% of poverty

Insured, not underinsured Underinsured* Uninsured during year

*Underinsured defined as insured all year but experienced: medical expenses 10% or more of income or 5% or more of incomes if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Data: 2003 Commonwealth Fund Biennial Health Insurance Survey (Schoen et al. 2005b)SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

ACCESS: UNIVERSAL PARTICIPATION

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THE COMMONWEALTH

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34

26

38

21

53 53

59

0

40

80

Total Income less than $40,000 Income $40,000 or more

AllInsured all yearUninsured during year

Medical Bill Problems or Accrued Medical Debt, 2005

Percent of adults (ages 19-64 yrs) with any medical bill problem or outstanding debt*

*Problems paying or unable to pay medical bills, contacted by a collection agency for medical bills, changed way of life to pay bills, or has medical debt being paid off over time.Data: Analysis of 2005 Commonwealth Fund Biennial Health Insurance Survey; Collins et al. 2006SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

By Income and Insurance Status

ACCESS: AFFORDABLE CARE

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THE COMMONWEALTH

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International Comparison of Spending on Health, 1980–2004

0

1000

2000

3000

4000

5000

6000

7000United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Data: OECD Health Data 2005 and 2006SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

0

2

4

6

8

10

12

14

16

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Average spending on health per capita ($US PPP)

Total expenditures on health as % GDP

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THE COMMONWEALTH

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Medicare Hospital 30-Day Readmission Rates, by Regions, 2003

18

1416

20

22

0

5

10

15

20

25

30

National Mean 10th 25th 75th 90th

Rate of hospital readmission within 30 days

Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2003 Medicare Standard Analytical Files 5% Inpatient DataSOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

Percentiles

EFFICIENCY

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THE COMMONWEALTH

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*Indexed to risk-adjusted 1 year survival rate (median= 0.70)**Risk-adjusted spending on hospital and physician services using standardized national pricesData: E. Fisher and D. Staiger, Dartmouth analysis of data from a 20% national sample of Medicare beneficiariesSOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

Quality and Costs of Care for Medicare Patients Hospitalized for Heart Attacks, Colon Cancer, and Hip Fracture, by Hospital Referral

Regions, 2000-2002

0.80

0.90

1.00

1.10

1.20

$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000

Relative Resource Use**

Qu

ali

ty o

f C

are

* (1

Ye

ar

Su

rviv

al

Ind

ex

, M

ed

ian

= 7

0%

)

Median Relative Resource Use = $25,994

EFFICIENCY

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THE COMMONWEALTH

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Percentage of National Health Expenditures Spent on Insurance Administration/Overhead, 2003

*Includes claims administration, underwriting, marketing, profits and other administrative costs. Data: OECD Health Data 2005SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

Net costs of health administration and health insurance as percent of national health expenditures

1.9 2.1 2.12.6

3.34.0 4.1 4.2

4.85.6

7.3

0

2

4

6

8

a

a2002 b1999

b

c2001

c *

EFFICIENCY

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THE COMMONWEALTH

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Physicians’ Use of Electronic Medical Records, U.S. Compared to Other Countries, 2000/2001

90 88

6258 56 55

5248

4237

30 29 2825

17 17 149

6 5

0

50

100

Percent of physicians

*2000Data: 2001 European Union EuroBarometer and 2000 Commonwealth Fund I Survey of Physicians (Harris Interactive 2002)SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

EFFICIENCY

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THE COMMONWEALTH

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Equitable Care: Summary Ratio Scores for Insurance, Income, Race/Ethnicity

Insured Compared to

Uninsured

High Income Compared to Low Income*

White Compared to

Black

White Compared to

Hispanic

EQUITY AVERAGE SCORE 66 62 76 80(Number of indicators) (17) (25) (25) (25)

Long, Healthy, and Productive Lives

NA 54 77 97

Quality

Getting the Right Care 63 71 80 72Safe Care 97 95 73 94Patient-Centered, Timely Care 51 57 78 64

Coordinated and Efficient Care 61 64 65 69

Universal Participation and Affordable Care 59 29 81 84

*Generally income compares either poor/near poor (<200% poverty) to those with incomes of 400% of poverty or higher or compares annual incomes of under $35,000 to incomes above $45,000. For mortality, income uses either census tract poverty rates or education level.

DIMENSION AVERAGES

EQUITY

SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

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THE COMMONWEALTH

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Diabetes*

144

527

185135

345

Congestive Heart Failure Pediatric Asthma

180

690

426

188

450

240

530

422

780

0

400

800

Adjusted rate per 100,000 population

Ambulatory Care Sensitive (Potentially Preventable) Hospital Admissions, by Race/Ethnicity and Patient Income Area, 2002

*Four diabetes complications-related admission measures are combined following AHRQ method: uncontrolled, short–term and long term complications, and lower extremity amputations. Data: Race/ethnicity estimates–HCUP and National Hospital Discharge Survey from AHRQ 2005a,2005b; Income Area = median income of patient zip code. NA = data not available. See chart pack technical appendix.SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

NA

EQUITY: COORDINATED AND EFFICIENT CARE

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THE COMMONWEALTH

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Six “Take Home” Messages Missed Opportunities and Implications

1. U.S. ranks poorly on key indicators despite far higher spending

– Internally we can see benchmarks of high performance

2. Guaranteeing affordable health insurance is essential to improve quality, access and efficiency

3. Quality and efficiency can be joint goals

– Quality varies widely; benchmarks can motivate change

– Variation puts patients at risk and drives up costs

4. Better connected care is integral to safety, reduced waste, and improved health outcomes

– U.S. under-invests in information systems and research

5. Net gains in efficiency are possible with incentives to improve

– Need to reinvest to improve coverage and system capacity

6. Transformation is urgently needed to secure a healthy nation

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THE COMMONWEALTH

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Scorecard Related Reports and Resources

• Health Affairs article available on line

– C. Schoen, et al. “U.S. Health System Performance: A National Scorecard,” Health Affairs, Web exclusive, Sept. 20, 2006.

• Available from the Fund at www.cmwf.org

– Commonwealth Fund Commission on a High Performance Health Care System, Why Not the Best? Results from a National Scorecard on the U.S. Health System Performance, September 2006.

– C. Schoen and S. How, National Scorecard on the U.S. Health System: Technical Report, September 2006.

– C. Schoen and S. How, National Scorecard on the U.S. Health System: Complete Chartpack and Chartpack Technical Appendix, September 2006.

• For other Commonwealth Fund Reports on System Performance, Quality, Insurance/Access and Equity visit the Fund website:

www. cmwf.org