The U.S. healthcare system is doing a dismal job delivering affordable, accessible and efficient care, the Commonwealth Fund concludes in a new report.

The Commonwealth Fund gave the nation's healthcare providers an overall performance score of 64 out of a possible 100, when compared with top performers across the U.S., and with other countries, in “Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011.”

That score slipped slightly from the organization's two previous national performance reports. In 2006, the country's overall score was 67 and in 2008, that number fell to 65.

“I wasn't really surprised that the score dropped,” said Cathy Schoen, senior vice president of the Commonwealth Fund. “We've been watching these indicators over time so we knew that access had declined and premiums are rising faster than incomes. We also know that administrative costs have remained high, and we're still lagging behind in health IT.”

The scorecard assesses health system performance using 42 indicators, covering areas such as equity, efficiency and quality. For instance, indicators of efficiency include rates of duplicate medical tests and preventable hospital readmissions.

Eighty-one million adults were without insurance or underinsured at some point in 2010—a steep jump from 61 million in 2003, according to the report. Also, only 4% of adults live in states where average insurance premiums are less than 15% of household income.

During an event marking the release of the report, Dr. David Blumenthal expressed dismay that being uninsured or underinsured was quickly becoming the norm. Blumenthal chairs the Commonwealth Fund's 17-member Commission on a High Performance Health System, which authored the report. He also is a faculty member at Harvard Medical School, Boston, and from April 2009 to April 2011 was HHS' national coordinator for healthcare information technology.

“There is an enormous amount of work to do,” Blumenthal said.

The news wasn't all bad, however.

The scorecard report noted big gains in some areas of clinical quality, credited largely to public-reporting efforts and other performance-improvement initiatives. The percentage of adults whose high blood pressure was under control grew from 31% in 1999 and 2000 to 50% in 2007 and 2008. The rate of hospitalized patients who received appropriate care for heart attack, heart failure and pneumonia rose from 84% to 96% over the same period.

“We were delighted to see the dramatic improvements in quality metrics, and particularly in hospital metrics,” Schoen said. “What we've always hoped with improvement efforts is that as people start to see their own performance and begin to ask how others were successful, the entire distribution would move up. And we're beginning to see that.”

For instance, in 2004, there was substantial variation in hospitals' prevention of surgical complications. In top-performing hospitals, 87% of surgical patients received appropriate care, such as antibiotics, to prevent complications, while only 49% of patients received such care at the lowest-performing hospitals. In 2009, those numbers increased to 98% of patients in top-performing hospitals and 90% of patients in the lowest group.

“That means that the bottom group's score is now higher than the top group's score was in 2004,” Schoen said. “Everyone is improving.”

Those pockets of success demonstrate the potential for more improvements down the road, said Maureen Bisognano, a member of the commission, and president and chief executive officer of the Cambridge, Mass.-based Institute for Healthcare Improvement. “I'm heartened by the progress we have made on quality indicators, particularly in this time of economic stress,” Bisognano said at the event.

Most of the data in the report is current through 2009, so it does not take into account the provisions of the healthcare reform law, Schoen said. Changes in payment models, expanded coverage and better care coordination will likely mean a better overall score when the next scheduled scorecard is released in 2014, provided those changes actually occur, she said.

“This report shows that when we focus, we can achieve pretty rapid progress in a short amount of time,” Schoen said. “But there is a real risk that if we don't move forward, we will see these problems continue.”