The ever-insightful Commonwealth Fund has just released its 2008 National Scorecard on Health System Performance, and reports that “the U.S. health system continues to fall far short of what is attainable, especially given the resources invested. Across 37 core indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with U.S. and international performance benchmarks.” According to Commonwealth’s metrics, overall performance has not improved since 2006.
As we mentioned recently, measuring performance in health care is a tough proposition, so it’s worth discussing Commonwealth’s rating system. The Scorecard looks at five components of what we might call "high-performance health care": healthy lives (preventable mortality & disability), quality (whether care is effective, coordinated, safe, and timely), access, efficiency (waste, appropriateness of care, administrative costs), and equity (disparities of care).
The scores of each dimension (out of a possible score of 100) are as
follows: healthy lives 72, quality 71, access 58, efficiency 53, and
equity 71. Looking at these scores, it seems that, all things
considered, quality measure up fairly well. But doesn’t that contradict
my last post?
Well, do we really
want to pat ourselves on the back for a C minus? I suppose we can take comfort
in the fact that our quality score is better than that of efficiency or equity, but that’s not much comfort.
Further, some of the
indicators that the Scorecard includes in categories other than quality
can easily be considered quality concerns, if we view quality
as a question of "appropriateness": getting people the most effective
care at the right time.
Delve into efficiency, for example–our lowest scoring category–and
you find data that seems very relevant to quality. For one,
Commonwealth reports that, in 2007, “U.S. patients were much more
likely—three to four times the benchmark rate—than patients in other
countries to report having had duplicate tests or that medical records
or test results were not available at the time of their appointment.”
This is not the right care at the right time. Duplicate tests do not
qualify as appropriate care–and neither do preventable
hospitalizations, which "remain high and variable across the country."
So depending on how you slice the data, you can probably get a slightly different–and perhaps an even less impressive–picture of health care performance, and quality in particular. There’s nothing particularly wrong with Commonwealth’s
methodology–it’s just that savvy readers should understand that every
assessment of health care "performance" and "quality" groups its metrics differently. This is a necessary evil for the purposes of measurement. In
the real world, health care is messy: high-performance health care is
all about how healthy lives, quality, access, efficiency, and equity
interact. None of them function in isolation of the others. As such,
the meatiest parts of the Scorecard aren’t the aggregate
scores of each category so much as their underlying data points. That’s where you see what’s really happening.
For example, regardless of whether you call it "efficiency" or
"quality," it’s telling that “rates of visits to physicians or
emergency departments for adverse drug effects increased by one-third
between 2001 and 2004” or that in 2005, “only half of adults received
all recommended preventive care."
Ultimately the Scorecard format is a great presentation tool, but the real power of Commonwealth’s assessment lies in the breadth and depth of its data, not just in its report card format.
Either way, Commonwealth’s take-home message crystal clear: our health care
system has a long way to go.
You can access the full scorecard here.
one man’s efficiency is another’s unemployment. look at the airline industry over past few decades. it is much more efficient. more people flying more places more cheaply and safely. are they happier? complaints about service suggest not. in meantime, lots of former airline employees are seeking work with comparable pay (and many remaining have taken pay cuts) while travel agents have become near extinct. making medicine more efficient would have much the same impact, which is why it is so strongly resisted.
one man’s efficiency is another’s unemployment. look at the airline industry over past few decades. it is much more efficient. more people flying more places more cheaply and safely. are they happier? complaints about service suggest not. in meantime, lots of former airline employees are seeking work with comparable pay (and many remaining have taken pay cuts) while travel agents have become near extinct. making medicine more efficient would have much the same impact, which is why it is so strongly resisted.
Many American health systems are significantly underinvested in quality management Infrastructure, Process, and Organization. Without an effective quality management foundation, it is unlikely that significant improvement in quality outcomes will occur. We believe that a “world class” quality management foundation includes:
Strategy: including a clear linkage of quality and patient safety to the organizational strategy and a Board-driven imperative to achieve quality goals.
Infrastructure: incorporating effective quality management technology, EMR and physician order entry, evidence based care development tools and methodologies, and quality performance metrics and monitoring technology that enables “real time” information.
Process: including concurrent intervention, the ability to identify key quality performance “gaps,” and performance improvement tools and methodologies to effectively eliminate quality issues.
Organization: providing sufficient number and quality of human resources to deliver quality planning and management leadership, adequate informatics management, effective evidence based care and physician order set development, performance improvement activity, and accredition planning to stay “survey ready every day.”
Culture: where a passion for quality and patient safety is embedded throughout the delivery system and leaders are incented to achieve aggressive quality improvement goals.
My firm has assisted a number of progressive health systems to achieve such a foundation, and to develop truly World Class Quality.
In my opinion before the quality discussion goes any further,I almost hate to say it, BUT, we need to start out with a discussionn on core values in US Health Care.
What do we as a nation REALLY believe in regarding health care? And are we willing to pay for it?
If we cannot(likely) achieve VALUES CONGRUENCE we can at least try for honest and transparant VALUES IDENTIFICATION.
Now that would be a good start.
What do you think?
Dr. Rick Lippin
Southampton,PA
“If we cannot(likely) achieve VALUES CONGRUENCE we can at least try for honest and transparant VALUES IDENTIFICATION.
Now that would be a good start.
What do you think?”
I agree. A fundamental issue still is this: is health care a right of all citizens or not? If we agree that it is, then we can proceed to defining what that right entails. To me, if we don’t agree health care is a right, then we will never unsnarl this mess.
Great point Jim. Every day I see people in the hospital in an administrative capacity and I wonder what it is that they actually do. When I ask the question, its similar to the scene from the movie Office Space. The two Bobs come to interview the Office Staff.
“What exactly do you say you do here?”
Multiply that by thousands of hospitals and on the other side with insurance companies and the red tape they have. With true reform, millions should be laid off to truly eliminate waste for those not directly involved with patient care. I hope reformers are comfortable with that. I hope alot of unemployed people are willing to fight the illegals for the “jobs americans won’t do”.
What to do with those bad Health Scorecards?
As many people reading this site already know, The Commonwealth Fund has released their National Scorecard U.S. Health System Performance for 2008 . The summary of their report is: Across 37 core indicators of performance, the U.S. achieves an overall
Jenga, I love that movie “Office Space” it is hilarious.
Jenga, I love that movie “Office Space” it is hilarious.