Evaluating Healthcare in America

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Parsing a comprehensive new report from the Commonwealth Fund, which finds that the healthcare system in the U.S. is, in general, declining, receiving the lowest score it ever has

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According to a comprehensive new report by the Commonwealth Fund, the healthcare system in the U.S. is, in general, declining. This year, the U.S. received a score of 64 out of a possible 100. In 2006, the U.S. got a 67 out of a possible 100, and in 2008 it earned a 65.

The report, entitled "Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011," covers key health indicators from the years 2008-2009, and is the third installment of the series that began in 2006.

The researchers, gathered from various hospitals and research institutions across the country, considered 42 key measures of healthcare in five different areas reflecting financial, medical, and human considerations:

  • Healthy Lives included variables having to do with life expectancy, mortality, and the prevalence of certain factors like smoking, and childhood overweight or obesity.
  • Quality measured how well medical care delivered its goals and whether it is "well coordinated, safe, timely, and patient-centered."
  • Access determined whether health care and health insurance were available to patients.
  • Efficiency looked at how smoothly operations run in the health business, including how often preventable re-admissions to hospitals occur and whether facilities are using information systems.
  • Equity assessed how different groups of patients are treated in the healthcare system.

COST AND CARE, TWO RELATED PROBLEMS

The main message of the report is that healthcare costs are rising but they are simply not matched by improvements in the care people receive. In other words, breaking it down to the most fundamental issues, there are two problems: Cost and care.

The total cost of healthcare -- which includes everything from primary care and preventative medicine to the treatment of chronic diseases to hospitalization and long-term care -- is rising faster than we can keep up, according to the report.

The U.S. spends twice per capita what other countries spend. The authors of the report comment that "U.S. health system performance continues to fall far short of what is attainable, especially given the enormity of public and private resources devoted nationally to health." The cost of healthcare is rising faster than the average American income, which leaves many people without access to insurance and health care at all.

Beyond the issue of cost, the quality of the care in the U.S. seems to be suffering. Measures like infant mortality and the number of unnecessary re-hospitalizations indicate that the U.S. still has a long road ahead. That said, there were some bright spots, signs that we may be on the right track, at least in some ways. For example, the U.S. is gaining ground in the management of certain chronic diseases and in the quality of long-term care, both of which are important markers for healthcare quality.

The authors argue that the Affordable Care Act will -- and has already begun to in some ways -- change the state of the heathcare system in the U.S. How far-reaching its effects will be remains to be seen.

WHERE THE U.S. SUCCEEDS

The U.S.'s overall score of 64 reflects a variety of strengths and weaknesses. The areas of improvement were not insignificant. In general, the U.S. showed promise in the control of chronic conditions, smoking rates, the use of electronic files for record keeping, and in certain aspects of hospital and long-term care. Breaking it down, we find the following trends.

  • Blood pressure control rose from 31 percent to 50 percent, which means that half the people with high blood pressure were managing it effectively, vs. less than a third at the previous measure, eight years earlier. Another chronic care marker reported nationally is long-term diabetes care (control of blood sugar), which did not improve, but remained fairly stable in 2007-2008, compared to four years earlier.
  • Cigarette smoking declined from 21 percent to 17 percent from 2004 to 2009.
  • The percentage of primary care doctors using electronic medical records (EMR) and information systems, increased from 17 percent to 46 percent from 2000 to 2009. However, the report also indicates that the use of EMR in the U.S. still lags far behind that of other countries.
  • Preventable mortality -- deaths that could have been avoided with earlier or more effective treatment measures -- improved by 21 percent, but because other countries, on average, improved by 32 percent on this measure, the U.S. fell last in preventable deaths.
  • Preventable hospitalizations such as admission rates for heart failure and pediatric asthma each dropped by 13 percentfrom 2004 to 2007, which may be a reflection of better disease management. Since preventable hospitalizations and re-hospitalizations are a major cause of economic stress to the health care system, reducing those is a major goal.
  • Some aspects of hospital care also improved. Hospitals reduced surgery complications 96 percent of the time in 2009, vs. only 71 percent in 2004.
  • Long-term care, which includes factors like the frequency of pressure ulcers in people living in nursing homes and the mobility of people with home health care aids, improved as well.

THE AREAS IN DECLINE

Despite progress in the areas above, there are three areas that show no improvement or have actually declined in recent years: healthcare, insurance accessibility, and cost of care. The issues, of course, are not completely separate from one another.

Falling Short on Measures of Overall Health

The U.S. scored 53 out of a possible 100, about the same as in previous reports, in a measure known as efficiency -- how well the healthcare system functions overall. Efficiency is a broad area, encompassing the "level of inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology." Here are some of the factors contributing to this score:

  • Premature deaths were 68 percent higher in the U.S. than in the best-performing countries. The premature death rate is an important measure of the quality of care, and includes all deaths that could have been avoided with better or earlier medical care.
  • Only 44 percent of Americans have a primary care doctor.
  • Only 50 percent of U.S. citizens received basic preventative care services in 2008, including immunization, screenings for cancer, and cholesterol and blood pressure tests. There was no significant change from 2002.
  • Only 43 percent of adults with a health problem in 2008 were able to get a doctor's appointment quickly when their condition required it.
  • Minorities, low-income and uninsured adults, and children were less likely to have access to health care and seek it in a timely way. These groups were also more likely to "experience poorly coordinated care, and to have untreated dental [problems], uncontrolled chronic disease, avoidable hospitalizations, and worse outcome" than their white, insured peers.
  • "Safe care" in hospitals was also weak: up to a quarter of seniors on Medicare were prescribed drugs that were "potentially inappropriate for older people." The researchers suggest that increasingly widespread use of electronic records systems could help improve safety in hospitals.
  • Infant mortality was twice as high as in other countries though it was down slightly, from seven to 6.8 deaths per 1,000 live births.
  • Childhood obesity rates continue to grow, with almost one-third of kids 10-17 overweight or obese. In some states, the number rises to 40 percent. The authors say that if it keeps going this way, the trend will negate the positive changes in other areas, like the decline in smoking.

Insurance: Poor Access and Affordability

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Alice G. Walton, PhD, is a health journalist and an editor at The Doctor Will See You Now.

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