"How to Improve? Pay Attention" by Robert Seifert

A letter to the editor about Senator Obama’s health care proposals in last Friday’s New York Times concludes, “There is no question that we spend a lot of money on health care in this country. Let’s not rule out the possibility that we are getting our money’s worth.” Sadly, it seems clear that the U.S. health care system overall is in fact not delivering value for our dollars, when compared with other countries or the highest performing states. This is the inescapable conclusion of the latest “National Scorecard on U.S. Health System Performance,” just published by The Commonwealth Fund.

The report scores the U.S. health system on 37 indicators in five areas: healthy lives (measures of mortality, life expectancy and limitations on activity); quality (effectiveness, coordination, safety and patient-centeredness of care); access (coverage and affordability); efficiency (administrative and clinical waste, inappropriate care or setting, readmissions); and equity (racial and ethnic disparities across select measures). Overall, the U.S. scores a 65 compared with a benchmark score of 100 and shows no improvement since the Fund published its first scorecard in 2006. Across the specific indicators, only 35 percent of them showed improvement from the 2006 report to 2008, while scores relative to benchmarks fell for 41 percent of the measures. It’s a discouraging assessment. As the authors put it: “The U.S. health system continues to exhibit suboptimal performance relative to what is achievable and to the resources invested.”

How do we improve?

One clue is found in the few measures where scores went up significantly from 2006 to 2008. All of these indicators have been a focus of concerted national initiatives supported by measurement and, in many cases, public reporting: controlling chronic disease such as diabetes and hypertension; hospital patients receiving recommended care for heart attack, heart failure and pneumonia; and hospital standardized mortality rates. The conclusion: “What receives attention gets improved.”

This is simple to the point of being obvious, and leads us to ask what other indicators are candidates for the attention treatment. A number of the national scorecard indicators have either declined substantially or are at a very low level, including (to name a few):
• Preventable mortality
• Hospital admissions and readmissions among nursing home residents
• Medical, medication or lab test errors
• Potential overuse or waste
• Use of emergency room for conditions that could have been treated in a doctor’s office

In Massachusetts, the list would be somewhat different (see, for example, data from the state scorecard the Commonwealth Fund published last year) but the principle is the same. Measure, report, and encourage organized improvement efforts. This is the philosophy underlying much of the work of the Health Care Quality and Cost Council, which is charged with setting and demonstrating progress toward achieving quality and cost goals for the Commonwealth. There is much to be gained by key health care players in Massachusetts examining the data together and coordinating behind a strategy to yield the maximum increase in value for the Commonwealth’s people. Not only will it improve lives; it will reduce costs in the bargain.

Robert Seifert is a Senior Associate in the Center for Health Law and Economics, Commonwealth Medicine, University of Massachusetts Medical School