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Publication Details

Publication Date: September 2006

Volume: 34

Authors: The Commonwealth Fund Commission on a High Performance Health System



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Why Not the Best? Results from a National Scorecard on U.S. Health System Performance


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Created by the Commonwealth Fund Commission on a High Performance Health System, the National Scorecard on U.S. Health System Performance is the first-ever comprehensive means of measuring and monitoring health care outcomes, quality, access, efficiency, and equity in one report. Its findings indicate that America's health system falls far short of what is attainable, especially given the resources the nation invests. Across 37 indicators of performance, the U.S. achieves an overall score of 66 out of a possible 100 when comparing actual national performance to achievable benchmarks. Scores on efficiency are particularly low. This report explains how the Scorecard works, describes results for each domain of performance, and discusses implications for policies to improve quality, access, and cost performance.

These findings are also discussed in a Health Affairs Web Exclusive.

Executive Summary

Once upon a time, it was taken as an article of faith among most Americans that the U.S. health care system was simply the best in the world. Yet growing evidence indicates the system falls short given the high level of resources committed to health care. Although national health spending is significantly higher than the average rate of other industrialized countries, the U.S. is the only industrialized country that fails to guarantee universal health insurance and coverage is deteriorating, leaving millions without aff ordable access to preventive and essential health care. Quality of care is highly variable and delivered by a system that is too often poorly coordinated, driving up costs, and putting patients at risk. With rising costs straining family, business, and public budgets, access deteriorating and variable quality, improving health care performance is a matter of national urgency.

The Commonwealth Fund Commission on a High Performance Health System has developed a National Scorecard on U.S. Health System Performance (see the table below for scores on 37 key indicators). The Scorecard assesses how well the U.S. health system is performing as a whole relative to what is achievable. It provides benchmarks for the nation and a mechanism for monitoring change over time across core health care system goals of health outcomes, quality, access, efficiency, and equity.

Scores come from ratios that compare the U.S. national average performance to benchmarks, which represent top performance. If performance in the U.S. was uniform for each of the health system goals, and if, in those instances in which U.S. performance can be compared with other countries, we were consistently at the top, the average score for the U.S. would be 100. But, the U.S. as a whole scores an average of 66. Several different measures or indicators were examined for each of the goal areas and dimensions of health system performance. There are wide gaps between national average rates and benchmarks in each of the dimensions of the Scorecard, with U. S. average scores ranging from 51 to 71.

By showing the gaps between national performance and benchmarks that have been achieved, the Scorecard offers performance targets for improvement. And it provides a foundation for the development of public and private policy action, and a yardstick against which to measure the success of new policies.

Scorecard Highlights and Leading Indicators
The table summarizes U.S. average rates on 37 indicators, their benchmark comparison rates—typically those achieved by the top 10 percent of countries, states, health plans, hospitals, or other providers—and the U.S. average score, calculated as the ratio between U.S. performance and benchmark rate. In just a few instances the benchmarks represent targets, rather than achieved top performance. The sources of the benchmarks are shown in the table.

Some major findings include:

Long, Healthy, and Productive Lives: Total Average Score 69

Quality: Total Average Score 71

Access: Total Average Score 67

Efficiency: Total Average Score 51

Equity: Total Average Score: 71

short report graphic

System Capacity to Innovate and Improve: Not Scored
Innovations in the ways care is delivered—from more integrated decision-making and information sharing to better workforce retention and teamoriented care—are necessary to make strides in all dimensions of care.

Investment in research to assess effectiveness, develop evidence-based guidelines, or support innovations in care delivery is low. The current federal investment in health services research, estimated at $1.5 billion, amounts to less than $1 out of every $1,000 in national health care spending. Ideally a national Scorecard would include indicators of the system's capacity to innovate and improve, but good indicators in this area are not currently available—itself a problem.

table image
View a complete version of this table on pages 10–11 of the report

Summary and Implications

The Case for a Systems Approach to Change
The Scorecard results make a compelling case for change. Simply put, we fall far short of what is achievable on all major dimensions of health system performance. The overwhelming picture that emerges is one of missed opportunities—at every level of the system—to make American health care truly the best that money can buy.

And let there be no doubt, these results are not just numbers. Each statistic—each gap in actual versus achievable performance—represents illness that can be avoided, deaths that can be prevented, and money that can be saved or reinvested. In fact, if we closed just those gaps that are described in the Scorecard—we could save at least $50 billion to $100 billion per year in health care spending and prevent 100,000 to 150,000 deaths. Moreover, the nation would gain from improved productivity. The Institute of Medicine, for example, estimates national economic gains of up to $130 billion per year from insuring the uninsured.

The central messages from the Scorecard are clear:

Our health system needs to focus on improving health outcomes for people over the course of their lives, as they move from place to place and from one site of care to another. This requires a degree of organization and coordination that we currently lack. Whether through more integrated health care delivery organizations, more accountable physician groups, or more integrated health information systems (in truth, likely all of these), we need to link patients, care teams, and information together. At the same time, we need to deliver safer and more reliable care.

Furthermore, the extremely high costs of treating patients with multiple chronic diseases, as detailed in this report, serve as a reminder that a minority of very sick patients in the U.S. account for a high proportion of national health care expenditures. Payment policies that support integrated, team-based approaches to managing patients with multiple, complex conditions—along with efforts to engage patients in care self-management—will be of paramount importance as the population continues to age.

By assessing the nation's health care against achievable benchmarks, the Scorecard, in a sense, tracks the vital signs of our health system. With rising costs and deteriorating coverage, leadership to transform the health system is urgently needed to secure a healthy nation.


The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 2006

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