THE COMMONWEALTH FUND Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011 Cathy Schoen, Senior Vice President.

THE COMMONWEALTH

FUND

Why Not the Best? Results from the National Scorecard

on U.S. Health System Performance, 2011

Cathy Schoen, Senior Vice President

The Commonwealth Fundwww.commonwealthfund.org

[email protected]

October 18, 2011

22011 Scorecard Methodology

• Third edition: same framework and methods as previous editions– Five dimensions of health system performance: healthy lives,

quality, access, efficiency, and equity– 42 indicators of health system performance

• Scores are simple ratios of U.S. average to benchmark– Benchmarks are levels achieved by other countries or top U.S.

states, regions, health plans, or providers (select indicators have policy goals or targets)

– Updates benchmarks whenever they improved

• To score dimensions, we average ratio scores for all indicators within dimension; dimension scores are then averaged for overall score

• Time trends capture at least three years of data; more than two-thirds span 5+ years

• Data primarily up through 2009, before reform

32011 Scorecard Overview Findings: Overall Score is 64 out of 100

• Overall U.S. health system performance relative to benchmarks failed to improve between 2006 and 2011 scorecards

– Performance compared with benchmarks improved on less than half of indicators

– Wide disparities by income, race/ethnicity persist

• Steep declines in access and affordability

• Substantial variation across the U.S., with as much as fourfold spread

• Uneven performance on quality, yet encouraging pockets of improvement

– Rapid progress on quality metrics that have been focus of national initiatives and public reporting

– Improvement on key quality metrics demonstrates significant progress possible when specific goals and targets set

• Broad evidence of inefficient care and high costs

• Substantial potential to improveTHE

COMMONWEALTH FUND

4

Average spending on healthper capita ($US PPP)

Total expenditures on healthas percent of GDP

*PPP= Purchasing power paritySource: OECD Health Data 2011 (June 2011).

International Comparison of Spending on Health, 1980–2009

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

5Scores: Dimensions of a High Performance Health System


* Note: Includes indicator(s) not available in earlier years.

75

70

67

52

69

67

73

71

57

53

71

65

70

75

55

53

69

64

0 100

Healthy Lives

Quality

Access

Efficiency

Equity

OVERALL SCORE

2006 revised

2008 revised

2011

6


76

88 8981

88

99 97

109116

106

97

134

115 113

127120

55 57 60 61 61 64 66 67 74 76 77 78 79 80 8396

0

50

100

150 1997–98 2006–07

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte, RAND Europe, and M. McKee, London School of Hygiene and Tropical Medicine, analysis of World Health Organization mortality files and CDC mortality data for U.S. (Nolte and McKee, 2011).

Mortality Amenable to Health Care

7

7.2 7.0 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8

10.311.1

10.2 9.9 9.9 9.610.1

10.810.0 9.9

5.3 5.1 5.0 4.9 4.8 4.7 4.7 5.0 5.0 5.0

0

4

8

12

U.S. average Bottom 10% states Top 10% states

International Comparison, 2007

2.02.5 2.6 2.7

3.1

4.0

5.1

6.8

Infant Mortality RateInfant deaths per 1,000 live births

^ Denotes years in 2006 and 2008 National Scorecards.Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003–2008; Mathews and MacDorman, 2011); international comparison—OECD Health Data 2011 (database), Version 06/2011.


U.S. National and State Trends

8Percent of Adults Ages 19–64 Uninsured by State

Data: U.S. Census Bureau, 2000–01 (revised) and 2010–11 Current Population Survey ASEC Supplement.

1999–2000median = 15.0%

2009–2010median = 19.4%

19%–22.9%

Less than 14%

14%–18.9%

23% or more


9Steep Decline in Access: 81 Million Uninsured and

Underinsured Adults, Up from 61 Million in 2003

9

Percent of adults ages 19–64 who are uninsured or underinsured


Insured all year, not underinsured

Underinsured*

Uninsured during year

Millions of adults ages 19–64 who are uninsured or underinsured, 2010

102

29

52

Total: 184 million**

35

42 44

* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income; medical expenses equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income.** Subgroups may not sum to total because of rounding.Data: 2003, 2007, and 2010 Commonwealth Fund Biennial Health Insurance Surveys.

10

Employer Premiums as Percentage of Median Household Income for Population Under Age 65

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 10

2003 2009

15%–17.9%

Less than 12%

12%–14.9%

18% or more

Data: Average total premiums—2003, 2005, and 2009 Medical Expenditure Panel Survey; state median income for single and family households (all under age 65) —2003–2004, 2005–2006, and 2009-2010 Current Population Survey.

WA

OR

ID

MT ND

WY

NV

CAUT

AZNM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SC

TNNC

KY

FL

OH

MI

WV

PA

NY

AK

MEVTNH

MA

RI

DE

DC

HI

CO

GAMS

OK

NJ

SD

VA

CT

MD

WA

OR

ID

MT ND

WY

NV

CAUT

AZNM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SC

TNNC

KY

FL

OH

MI

WV

PA

NY

AK

MEVTNH

MA

RI

DE

DC

HI

CO

GAMS

OK

NJ

SD

VA

CT

MD

HI HI

11

31

45

27

6066

53

Total Under 200% ofpoverty

200% of poverty ormore

Insured all year Uninsured during year

3440

0

25

50

75

100

2005 2010

Medical Bill Problems or Medical Debt, 2010

By income and insurance status, 2010U.S. average

Percent of adults ages 19–64 with any medical bill problem or outstanding debt*

* Problems paying or unable to pay medical bills, contacted by a collection agency for medical bills, had to change way of life to pay bills, or has medical debt being paid off over time.Data: 2005 and 2010 Commonwealth Fund Biennial Health Insurance Surveys.


12

45

64

55

53

55

55

60

45

56

63

42

0 20 40 60 80 100

Uninsured part year

Insured all year

<200% of poverty

200%–399% of poverty

400%+ of poverty

Hispanic

Black

White

2008

2005

2002

U.S. Variation 2008

U.S. Average


Percent of adults ages 19–64 with an accessible primary care provider*

Adults with an Accessible Primary Care Provider

* An accessible primary care provider is defined as a usual source of care who provides preventive care, care for new and ongoing health problems, referrals, and who is easy to get to and easy to contact by phone during regular office hours.Data: N. Tilipman, Columbia University analysis of Medical Expenditure Panel Survey.

13Receipt of Recommended Screening and Preventive

Care for Adults

* Recommended care includes at least six key screening and preventive services: blood pressure, cholesterol, Pap, mammogram,fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot. See Appendix B for complete description.Data: N. Tilipman, Columbia University analysis of Medical Expenditure Panel Survey.


32

46

56

41

49

60

51

50

49

0 20 40 60 80 100

Uninsured all year

Uninsured part year

Insured all year

<200% of poverty

200%–399% of poverty

400%+ of poverty

2008

2005

2002

U.S. Variation 2008

U.S. Average

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

14

Chronic Disease Under Control: Diabetes and Hypertension

85

49

76

55

72

29

Diabetes under control* High blood pressure undercontrol**

Private Public Uninsured

*Refers to diabetic adults whose hemoglobin A1c is <9.0% **Refers to hypertensive adults whose blood pressure is <140/90 mmHg. Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.

79

31

88

41

86

50

0

25

50

75

100

Diabetes under control* High blood pressure undercontrol**

1999–2000 2003–2004 2007–2008

Percent of adults age 18+

U.S. Average By Insurance, 2005–2008


Percent of nonelderly adults ages 18–64

15

87

59

49

9389

83

74

66

98 97 96 9490

71

81

0

25

50

75

100

90th %ile 75th %ile Median 25th %ile 10th %ile

2004 2006 2009

Hospitals: Prevention of Surgical Complications


Percent of adult surgical patients who received appropriate care to prevent complications*

* See Appendix B for methods and description of clinical indicators.Data: IPRO analysis of data from CMS Hospital Compare.

16

Prescription of Potentially Unsafe Medications Among Elderly Beneficiaries, by Hospital Referral Regions, 2007

25

1821

31

36

0

10

20

30

40

50

Median 10th %ile 25th %ile 75th %ile 90th %ile

Percent of elderly Medicare beneficiaries

20

1517

23

26

Median 10th %ile 25th %ile 75th %ile 90th %ile

Use of high-risk medication*Potentially harmful

drug–disease interactions**

* Medicare beneficiary received at least one drug from a list of 13 classes of high-risk prescriptions that should be avoided by the elderly. ** Medicare beneficiaries with dementia, hip or pelvic fracture, or chronic renal failure, and received a prescription in an ambulatory care setting that is contraindicated for the condition. Data: Y. Zhang analysis of 5% sample of Medicare beneficiaries enrolled in stand-alone Medicare Part D plans (Zhang et al., 2010).


17

20

1618

2224

1618

22 222020

0

10

20

30

2003 2005 2009 10th 25th 75th 90th 10th 25th 75th 90th

Medicare Hospital 30-Day Readmission Rates Remain High

Hospital Referral Region percentiles, 2009

State percentiles, 2009


Percent of Medicare beneficiaries initially admitted for one of 45 medical conditions or surgical procedures who are readmitted within 30 days following discharge*

* See Appendix B for list of conditions and procedures used in the analysis.Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data.

U.S. average

18

Potentially Preventable Hospital Admissions for Select Ambulatory Care Sensitive Conditions

156

49

230

49

209

135

U.S.average

Top 10%states

Bottom 10%states

202

104

251205

108

251

U.S.average

Top 10%states

Bottom 10%states

2004 2007

Adjusted rate per 100,000 population*

476

246

634

545

211

416

0

100

200

300

400

500

600

700

U.S.average

Top 10%states

Bottom10% states

Diabetes**Heart failure Pediatric asthma

* Rates are adjusted by age and gender using the total U.S. population for 2000 as the standard population.** Combines three diabetes admission measures: uncontrolled diabetes without complications, diabetes with short-term complications, and diabetes with long-term complications. Data: U.S. average—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; State distribution—State Inpatient Databases; not all states participate in HCUP (AHRQ 2010).


19

Nursing Homes: Hospital Admission and Readmission Rates Among Nursing Home Residents, by Hospital Referral Regions

18

13

24

20

15

25

21

16

26

Median 10th %ile 90th %ile

2000 2004 2008

18

11

26

20

12

28

20

12

28

0

20

40

Median 10th %ile 90th %ile

2000 2004 2008

Data: V. Mor and Z. Feng, Brown University analysis of Medicare enrollment data and Part A claims data for all Medicare beneficiaries who entered a nursing home and had a Minimum Data Set assessment.


Percent of long-stay nursing home residents hospitalized over a six-month period

Percent of first-time nursing home residents rehospitalized within 30 days of hospital discharge to nursing home

20

Use of Electronic Medical Records


17

28

46

97 97 96 95 94 94

7268

37

99

0

25

50

75

100

2000 2006 2009 NETH NZ NOR UK AUS ITA SWE GER FRA CAN

International Comparison, 2009

Percent of primary care physicians using electronic medical records

United States

AUS=Australia; CAN=Canada; FRA=France; GER=Germany; ITA=Italy; NETH=Netherlands; NZ=New Zealand; NOR=Norway; SWE=Sweden; UK=United Kingdom.Data: Commonwealth Fund International Health Policy Survey of Physicians.

21

International Comparison of Spending on Insurance Administration, 2009

a 2008* Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance. NHE=National Health ExpendituresData: OECD Health Data 2011 (database), Version 06/2011.


Percent of NHE Per capita ($US PPP)

Japana 1.9% $53.6

Finland 2.1% $63.2

Australiaa 3.6% $118.3

Austria 3.6% $146.8

Canada 3.7% $153.3

Netherlands 4.0% $185.1

Switzerland 4.9% $253.2

Germany 5.4% $221.8

France 7.0% $270.8

United States* 7.0% $531.5

22Potential to Improve: National AnnualGains if Reach Benchmark Performance

• Up to 91,000 fewer deaths before age 75 from causes potentially preventable with timely and appropriate health care if the U.S. achieved best country rate; 84,000 if achieved lowest 3 countries

• 66 million more adults would receive recommended screenings and preventive care at appropriate ages according to guidelines

• 38 million more adults ages 19–64 would have an accessible primary care provider

• $55 billion in saving in insurance administrative costs if the U.S. achieved levels of other countries with competing private insurance plans– $114 billion if U.S. achieved levels of lowest rate countries– Does not include potential savings to physicians and hospitals

from reduced complexity

23

Data: U.S. Census Bureau, 2010–11 Current Population Survey ASEC Supplement; estimates for 2019 by Jonathan Gruber and Ian Perry of MIT using the Gruber Microsimulation Model for The Commonwealth Fund.

Post-Reform: Projected Percent of Adults Ages 19–64 Uninsured by State


2009–2010median = 19.4%

2019 (estimated)median = 8.4%

19%–22.9%

14%–18.9%

23% or more

8%–13.9%

Less than 8%

23

WA

OR

ID

MT ND

WY

NV

CAUT

AZNM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SC

TNNC

KY

FL

OH

MI

WV

PA

NY

AK

MEVTNH

MA

RI

DE

DC

HI

CO

GAMS

OK

NJ

SD

VA

CT

MD

WA

OR

ID

MT ND

WY

NV

CAUT

AZNM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SC

TNNC

KY

FL

OH

MI

WV

PA

NY

AK

MEVTNH

MA

RI

DE

DC

HI

CO

GAMS

OK

NJ

SD

VA

CT

MD

24Summary and Implications

• Access is an essential foundation for improvement– U.S. losing ground in ensuring access to affordable health care– Access to care, health care quality, and efficiency are interrelated

• What receives attention gets improved– Focused quality improvement and public reporting initiatives have led to

significant gains– Measurable and actionable benchmarks provide targets to improve– Gaps between average performance and benchmarks remain large,

underscoring potential gains• Better primary care and care coordination needed to improve outcomes at lower

costs– Strengthen primary care system to ensure access, ongoing care management,

and care coordination– Improve transitions and follow-up care after hospitalization needed

• Align incentives to promote more effective and efficient use of staff, IT, and clinical resources

25

Affordable Care Act Reforms on Target

• Insurance reforms will provide foundation for affordable, comprehensive insurance

• Payment and care system reforms targeted on gaps, wide variations across the United States

• Investment in information systems to guide and inform action

• Emphasis on primary care and coordination, with patient-centered care teams

• Accountability for health, care, and cost outcomes

• Should expect to see positive scorecard results in the future

26

For More Information Visit the Fund’s website atwww.commonwealthfund.org

Why Not the Best provides comparative data for hospitals. To access: www.whynotthebest.org

THE COMMONWEALTH FUND Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011 Cathy Schoen, Senior Vice President.

Documents

health care slide

health plans

commonwealth fund slide

scorecards performance

uneven performance

national scorecards

years of data

years data