2016 National Healthcare Quality and Disparities Report

Overview of Quality and Access in the U.S. Health Care System

The National Strategy for Quality Improvement in Health Care (National Quality Strategy, or NQS) (U.S. Department of Health and Human Services, 2011) identified three aims that form an overarching framework for this discussion of health care quality: Achieving Better Care, Achieving Healthy People/Healthy Communities, and Making Care Affordable. Although progress is being made toward these aims, variations persist among states and across health care settings.

Three Aims for Improving Health Care

The three aims for improving health care are used to guide quality improvement efforts and are used as the framework of the National Healthcare Quality and Disparities Report (QDR).

Aim 1: Achieving Better Care

Achieving Better Care requires coordinating services across a complex health care system. The health care industry employs millions of workers providing billions of services each year. Improving care requires facilities and providers to work together to expand access, enhance quality, and reduce disparities.

The QDR tracks care delivered by providers in many types of health care settings. While health is affected by many factors besides health care, receipt of appropriate high-quality services and counseling about healthy lifestyles can facilitate the maintenance of well-being and functioning.

Figure 1. Number of health care service encounters, United States, 2012, 2013, 2014

Bar graph showing number of health care service encounters by millions in visits or days: Hospice Days (2014) - 116.78; Hospital Days (2013) - 216.04; Nursing Home Days (2014) - 500.26; Home Health Care Visits (2014) - 114.24; Hospital Outpatient Visits (2013) - 787.42; Physician Office Visits (2012) - 928.63.

Source: National Center for Health Statistics (NCHS), Health, United States, 2015 (physician [Table 76] and hospital visits [Table 82]) (https://www.cdc.gov/nchs/hus/index.htm); NCHS, Long-term care providers and services users in the United States: data from the National Study of Long-Term Care Providers, 2013-2014 (https://www.cdc.gov/nchs/data/series/sr_03/sr03_038.pdf) (nursing home days); Medicare Payment Advisory Commission (MedPAC), Health care spending and the Medicare Program: a data book, June 2016 (http://medpac.gov/docs/default-source/data-book/june-2016-data-book-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0) (home health [Table 8-9]) and hospice data [Table 11-7]).
Note: Hospital outpatient visits include visits to the emergency department, outpatient department, referred visits (pharmacy, EKG, radiology), and outpatient surgery. Data shown represent the latest year for which data were available.

  • In 2012, there were 929 million physician office visits, including visits to physicians in health centers (Figure 1).
  • In 2013, there were 787 million hospital outpatient visits, and 114 million home health visits.
  • In 2014, patients spent 500 million days in nursing homes, 216 million days in hospitals, and 117 million days under hospice care.

Figure 2. Number of people working in health occupations, United States, 2015

Bar graph showing number of people working in health occupations, by thousands: Other Health Occupations - 1,452; Aides - 2,538; Health Technologists - 2,303; Emergency Medical Technicians and Paramedics - 237; Other Health Practitioners - 349; Pharmacists - 296; Therapists - 628; Registered Nurses - 2,746; Advanced Practice Nurses - 183; Dentists (2013) - 191; Doctors of Medicine (2013) - 855.

Source: National Center for Health Statistics, Health, United States, 2015 (https://www.cdc.gov/nchs/hus/index.htm) (doctors and dentists); and Bureau of Labor Statistics Occupational Employment Statistics (https://www.bls.gov/oes/), 2015 (all other occupations).
Note: Doctors of Medicine includes Doctors of Osteopathic Medicine. Other health practitioners include physician assistants, chiropractors, dietitians and nutritionists, optometrists, podiatrists, and audiologists. Aides include nursing, psychiatric, home health, occupational therapy, and physical therapy assistants and aides.

  • In 2013, there were 855,000 doctors of medicine, which includes active doctors of medicine and doctors of osteopathy, and 191,000 dentists working in the United States (Figure 2).
  • In 2015, there were also 2.7 million registered nurses, 2.3 million health technologists, and 2.5 million nursing and other aides.
  • In 2015, 349,000 other health practitioners provided care, including more than 98,000 physician assistants.

The numbers of health service encounters and people working in health occupations illustrate the large scale and inherent complexity of the U.S. health care system. The tracking of health care quality measures in this report, notably in the Trends in Quality section, attempts to quantify the progress made in improving quality and reducing disparities in the delivery of health care to the American people.

Aim 2: Achieving Healthy People/Healthy Communities

Achieving Healthy People/Healthy Communities requires optimizing population health by mitigating the effects of the leading causes of morbidity and mortality. Care for most of these conditions is tracked in the QDR. Variation in access to care and care delivery across communities contributes to disparities related to race, ethnicity, and socioeconomic status.

Figure 3. Years of potential life lost before age 65, 2015

Bar graph showing years of potential life lost (YPLL) before age 65 at an age-adjusted rate of YPLLs per 100,000: Cerebrovascular - 77.45; Diabetes - 85.64; Liver Disease - 107.54; Congenital Anomalies - 166.4; Homicide - 206.41; Perinatal Period - 302.11; Suicide - 323.3;  Heart Disease - 464.29; Cancer - 583.2; Unintentional Injury - 896.42.

Key: YPLL = years of potential life lost.

Source: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Years of Potential Life Lost (YPLL) Reports, 1999 – 2015. https://webappa.cdc.gov/sasweb/ncipc/ypll10.html.

  • The three leading diseases and injuries contributing to years of potential life lost (YPLLs) (unintentional injury, cancer, and heart disease) did not change between 2005 and 2015 (Figure 3).
  • From 2005 to 2015, there was a 22% increase in YPLLs caused by suicide, moving its rank from number 5 to number 4.
  • From 2005 to 2015, YPLLs caused by HIV decreased by 65%, moving from 8 to 11 in the ranking (data not shown). Diabetes moved from 11 to 9 in the ranking.

Figure 4. Leading causes of death for the total population, United States, 2015

Bar graph showing leading causes of death for the total population, at a crude rate per 100,000 standard population: Suicide - 11.8; Kidney Disease - 14.8; Pneumonia and Flu - 19.3; Diabetes - 24.2; Alzheimer's Disease - 24.6; Unintentional Injuries - 39.4; Chronic Lower Respiratory Diseases - 44.6; Cerebrovascular Disease - 47.7; Cancer - 188.7; Heart Disease - 214.

Source: Centers for Disease Control and Prevention. National Center for Health Statistics, atNational Vital Statistics System—Mortality. https://www.cdc.gov/nchs/data/databriefs/db267_table.pdf#3.

  • Heart disease, cancer, cerebrovascular disease, chronic lower respiratory diseases, unintentional injuries, and diabetes were among the leading causes of death for the overall U.S. population (Figure 4).

The years of potential life lost and leading causes of death illustrate the burden of disease experienced by the American people. Findings highlighted in the Trends in Quality section of this report attempt to quantify progress made in improving the quality of care and reducing disparities in health care and ultimately reducing disease burden.

Aim 3: Making Care Affordable

Making Care Affordable requires smarter spending of limited health care dollars. Health care is costly. In 2015, U.S. health care spending increased 5.8 percent to reach $3.2 trillion, or $9,990 per person. In addition, the overall share of the U.S. economy devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014 (CMS, 2015).

Multiple sources of fragmented expenditures channeled to both the public and private sectors of care make it challenging to control growth in health care costs. New delivery system models such as the patient-centered medical home (PCMH) have been developed that coordinate care across sectors and may help ensure that money is spent efficiently.

Figure 5. Personal health care expenditures, by type of expenditure, 2014

Pie chart showing personal health care expenditures, by type of expenditure: Hospital Care - 40.1; ; Physician and Clinical Services - 24.9; ; Prescription Drugs - 12.3; ; Nursing Care - 6.4; ; Other Health Care - 6.2; ; Dental Services - 4.7; ; Home Health Care - 3.4; ; Durable Equipment - 1.9.

Source: CMS, National Health Expenditures Account, as reported in NCHS, Health, United States, 2015. https://www.cdc.gov/nchs/hus/index.htm.
Note: Personal health care expenditures are outlays for goods and services related directly to patient care. These expenditures are total national health expenditures minus expenditures for investment, health insurance program administration and the net cost of insurance, and public health activities.

  • In 2014, hospital care expenditures were $971.8 billion, 40% of personal health care expenditures (Figure 5).
  • Expenditures for physician and clinical services were $603.7 billion while expenditures for dental services were $113.5 billion, 25% and 5% of personal health care expenditures, respectively.
  • Prescription drug expenditures were $297.7 billion, 12% of personal health care expenditures.
  • Nursing care facility expenditures were $155.6 billion and home health care expenditures were $83.2 billion, or 6% and 3% of personal health care expenditures, respectively.

Figure 6. Personal health care expenditures, by source of funds, 2014

Pie chart showing personal health care expenditures, by source of funds: Private - 35.2; Medicare - 23.5; Medicaid - 18.0; Out of Pocket - 13.4; Other Third Party - 9.5; Children's Health Insurance Program - 0.4.

Source: Centers for Medicare & Medicaid Services, National Health Expenditures Account, as reported in Health, United States, 2015.
Note: Personal health care expenditures are outlays for goods and services related directly to patient care. These expenditures are total national health expenditures minus expenditures for investment, health insurance program administration and the net cost of insurance, and public health activities.

  • In 2014, private insurance accounted for 35% of personal health care expenditures, followed by Medicare, Medicaid, and out of pocket (Figure 6).
  • Sources of funds varied by type of expenditure (data not shown):
    • Private insurance accounted for 37% of hospital, 42% of physician, 10% of home health, 8% of nursing home, and 43% of prescription drug expenditures.
    • Medicare accounted for 26% of hospital, 23% of physician, 42% of home health, 23% of nursing home, and 29% of prescription drug expenditures.
    • Medicaid accounted for 17% of hospital, 11% of physician, 36% of home health, 32% of nursing home, and 9% of prescription drug expenditures.
    • Out-of-pocket payments accounted for 3% of hospital, 9% of physician, 9% of home health, 27% of nursing home, and 15% of prescription drug expenditures.

Personal health expenditures illustrate the economic burden of disease and barriers to access to health care. Findings from the Access and Disparities in Access to Health Care section of this report show the progress and opportunities for improvement in overcoming these barriers.

Return to Contents

Variation in Health Care Quality and Disparities

State-level data show that health care quality and disparities vary widely depending on state and region. Although a state may perform well in overall quality, the same state may face significant disparities in health care access and quality.

Figure 7. Overall quality of care, by state, 2014-2015

Map of the United States showing quality in quartiles by state, with the first quartile the lowest and the fourth quartile the highest: Quartile 1: Alaska, Arkansas, Indiana, Kentucky, Louisiana, Mississippi, Nevada, New Mexico, Oklahoma, Oregon, Texas, West Virginia, Wyoming. Quartile 2: Colorado, Connecticut, Hawaii, Idaho, Maryland, Michigan, Missouri, North Carolina, South Carolina, South Dakota, Utah, Vermont, Virginia. Quartile 3: Alabama, Arizona, California, District of Columbia, Florida, Georgia, Illinois, Kansas, Montana, New York, Ohio, Tennessee, Washington. Quartile 4: Delaware, Iowa, Maine, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, North Dakota, Pennsylvania, Rhode Island, Wisconsin.

Note: All measures in the report with state-level data are used to compute an overall quality score for each state based on the number of quality measures above, at, or below the average across all states. States were ranked and quartiles are shown on the map. The states with the worst quality score are in the first quartile, and states with the best quality score are in the fourth quartile.

  • The overall quality of care varied across the United States (Figure 7):
    • Some states in the Midwest (Iowa, Minnesota, Nebraska, North Dakota, and Wisconsin) and some in the Northeast (Delaware, Maine, Massachusetts, New Hampshire, New Jersey, Pennsylvania, and Rhode Island) had the highest overall quality scores. Scores were based on the number of measures that were better, same, or worse than the national average for each measure.
    • Many Southern and Southwestern states (Arkansas, Kentucky, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, and West Virginia), several Western states (Nevada, Oregon, and Wyoming), and one Midwestern state (Indiana) had the lowest overall quality scores.

Figure 8. Average differences in quality of care for Blacks, Hispanics, and Asians compared with Whites, by state, 2014-2015

Map of the United States showing disparities in quartiles by state, with the first quartile the lowest (best) and the fourth quartile the highest (worst): Quartile 1: Alaska, Hawaii, Idaho, Kansas, Kentucky, Maryland, North Dakota, South Dakota, Tennessee, Utah, Virginia, Wyoming. Quartile 2: Alabama, Connecticut, Georgia, Michigan, Mississippi, Missouri, Nevada, New Hampshire, New Jersey, Rhode Island, South Carolina, Vermont, Washington. Quartile 3: Arkansas, California, Colorado, Delaware, Florida, Louisiana, Maine, Montana, Nebraska, New Mexico, Oklahoma, Oregon, West Virginia. Quartile 4: Arizona, District of Columbia, Illinois, Indiana, Iowa, Massachusetts, Minnesota, New York, North Carolina, Ohio, Pennsylvania, Texas, Wisconsin.

Note: All measures in this report that had state-level data to assess racial/ethnic disparities were used, Separate quality scores were computed for Whites, Blacks, Hispanics, and Asians. For each state, the average of the Black, Hispanic, and Asian scores was divided by the White score. State-level AI/AN data were not available for analysis. States were ranked on this ratio, and quartiles are shown on the map. Disparity scores were not risk adjusted for population characteristics in each state. The states with the worst disparity score are in the fourth quartile, and states with the best disparity score are in the first quartile.

  • Racial and ethnic disparities varied across the United States (Figure 8):
    • Some Western and Midwestern states (Idaho, Kansas, North Dakota, South Dakota, Utah, and Wyoming and several Southern states (Kentucky, Tennessee, and Virginia) had the fewest racial and ethnic disparities overall.
    • Several Northeastern states (Massachusetts, New York, and Pennsylvania), some Midwestern states (Illinois, Indiana, Iowa, Minnesota, Ohio, and Wisconsin), one Southern state (North Carolina), one Southwestern state (Texas), and one Western state (Arizona) had the most racial and ethnic disparities overall.

Return to Contents

Page last reviewed July 2017
Page originally created July 2017
Internet Citation: Overview of Quality and Access in the U.S. Health Care System. Content last reviewed July 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqdr16/overview.html