The Washington Post reports that U.S. Health Care [is] Still Ill. This conclusion comes from a report from the Commonwealth Fund titled Results from the National Scorecard on U.S. Health System Performance, 2008. Even though the U.S. still spends more money on medical care than any other nation, performance on the Scorecard has not improved between 2006 and 2008.
Today, let’s look into some of these measures in detail.
- Preventable Deaths/100,000 Population. This is calculated as the annual ratio of people below age 75 or below who die from diseases such as heart disease, stroke, bacterial infection, diabetes. These figures are age-adjusted so that if one country has a lot of old people, this does not count against them. This is a very good aggregate metric of how well the health care system is doing and it turns out that the U.S. is in last place.
- Percent of adults (18+) who received all recommended screening and preventive care. Here we see pretty much no change between 2002 and 2005 (49% to 50%). However, using a metric such as all preventive care hides some improvements along the margin. For instance, let us assume that there are 5 key vaccines. If and half the population get all the vaccines and half of the population did not, then we would have a 50% score on this metric. On the other hand, if we had a huge improvement where the people who were not getting vaccinated now got 3 of the 5 vaccines, we would still be at the same 50% mark.
- Quality of Care. We note that in most of the measurable quality metrics, performance increased. The number of diabetics with HbA1C<9% increased; the percent of people who received the proper care for heart attacks, heart failure and pneumonia increased as well. We see that more and more patients now receive written instructions after they are discharged from a hospital. Much of this improved quality may be coming from pay-for-performance interventions. As I have mentioned in earlier blog posts, P4P may improve the quality of care on measured dimensions, while reducing the quality of care in unmeasured areas.
- Nursing Home hospitalizations. The percent of nursing home patients who were hospitalized in a year increased. This may be due to worse care, or an older–and thus generally sicker–population of adults being the ones who enter into nursing homes.
- Off-Hours care: Although there was some improvement from 2005, Americans in 2007 were the least likely to be able to receive non-emergency care on nights, weekends, and holidays.
- Access: The percent of people who are uninsured has risen greatly between 2000 and 2006. Further, 41% of adults have an outstanding medical debt of bill problem.
- Coordination of care. When Americans have test done, they are the least likely to have these results available at the time of the next appointment. Among countries in the Commonwealth Report, only Canadians primary care physicians (PCPs) are less likely to use electronic medical records than American PCPs.
Can these report cards help improve care? Yes an no. Of course, pointing out short-comings in the American system is the first step that is needed in order to improve care. The report, however, does not really explain why these short falls are occurring or how to fix them. Are adult preventive care levels low because physicians are not doing their job, or are patients avoiding needed checkups? The answer to this question will determine whether a physician-focused or public health-focused approach would work best. Similarly, we see that nursing home hospitalization are increasing. Why is this? Is this because of worse nursing home care or are the patients who enter into nursing homes sicker on average in more recent years? The the former is the culprit, what specific problems are leading to more hospitalizations and how can we fix them.
I applaud the Commonwealth Fund for collecting this data. As they wisely state, “what receives attention gets improved.” However, more detail studies are needed if we really want to improve the quality, access and efficiency of health care in the 21st century.