AIMING HIGHER Results from a State Scorecard on Health System Performance, 2009 T h e C o m m o n w e a lt h F u n d C o m m i s s i o n o n a H i g h P e r f o r m a n c e H e a lt h S y s t e m O C T O B ER 2 0 0 9 t h e c o m m o n w e a lt h f u n d c o m m i s s i o n o n a h i g h p e r f o r m a n c e h e a lt h s y s t e m Membership James J. Mongan, M.D. Fernando A. Guerra, M.D. Louise Y. Probst Chair of the Commission Director of Health Executive Director President and Chief Executive Officer San Antonio Metropolitan Health District St. Louis Area Business Health Coalition Partners HealthCare System, Inc. Glenn M. Hackbarth, J.D. Sandra Shewry Maureen Bisognano Consultant Founding President and Executive Vice President and Chief Executive Officer Chief Operating Officer George C. Halvorson California Center for Connected Health Institute for Healthcare Improvement Chairman and Chief Executive Officer Kaiser Foundation Health Plan Inc. Glenn D. Steele, Jr., M.D., Ph.D. Sandra Bruce President and Chief Executive Officer President and Chief Executive Officer Robert M. Hayes, J.D. Geisinger Health System Resurrection Health Care Senior Vice President, Health Quality Universal American Corporation Alan R. Weil, J.D. Christine K. Cassel, M.D. Executive Director President and Chief Executive Officer Sheila T. Leatherman National Academy for State Health Policy American Board of Internal Medicine Research Professor President and ABIM Foundation School of Public Health Center for Health Policy Development University of North Carolina Michael Chernew, Ph.D. Visiting Professor, London School _____________________________________ Professor of Economics Department of Health Care Policy Stephen C. Schoenbaum, M.D. Harvard Medical School Gregory P. Poulsen Executive Director Senior Vice President Executive Vice President for Programs Patricia Gabow, M.D. Intermountain Health Care The Commonwealth Fund Chief Executive Officer Denver Health Neil R. Powe, M.D. Cathy Schoen Chief, Medical Services Research Director San Francisco General Hospital Senior Vice President for Research Constance B. Wofsy and Evaluation Distinguished Professor and The Commonwealth Fund Vice-Chair of Medicine University of California, San Francisco t h e c o m m o n w e a lt h f u n d The Commonwealth Fund, among the first private foundations The Fund carries out this mandate by supporting inde- started by a woman philanthropist—Anna M. Harkness—was pendent research on health care issues and making grants established in 1918 with the broad charge to enhance the to improve health care practice and policy. An international common good. program in health policy is designed to stimulate innovative The mission of The Commonwealth Fund is to promote a policies and practices in the United States and other industrial- high performing health care system that achieves better access, ized countries. improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. COVER PHOTO COURTESY OF CAREOREGON, OLD TOWN CLINIC Aiming Higher R e s u lt s f r o m A Stat e Sc o r e c a r d o n H e a lt h S y s t e m P e r f o r m a n c e , 2 0 0 9 Douglas McCarthy, Sabrina K. H. How, and Cathy Schoen The Commonwealth Fund Joel C. Cantor and Dina Belloff Rutgers University Center for State Health Policy On behalf of the Commonwealth Fund Commission on a High Performance Health System October 2009 ABSTRACT: Focused on identifying opportunities to improve, The Commonwealth Fund’s State Scorecard on Health System Performance assesses states’ performance on health care relative to achievable benchmarks for 38 indicators of access, quality, costs, and health outcomes. The 2009 State Scorecard paints a picture of health care systems under stress, with deteriorating health insurance coverage for adults and rising health care costs. On a positive note, there were gains in children’s coverage as a result of national reforms, and improvement in some measures of hospital and nursing home care following federal efforts to publicly report quality data. The scorecard highlights persistent wide variation in performance across states and continued evidence of poor care coordination. Increasing cost pressures and deterioration in access across the U.S., together with geographic disparities in performance, underscore the urgent need for comprehensive national reforms to ensure access, change the trajectory of costs, and enhance value. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff, or of The Commonwealth Fund Commission on a High Performance Health System or its members. This report, related state tables, and other Fund publications are available online at www.commonwealthfund.org. To learn about new publications when they become available, visit the Fund Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1326. PHOTO: JOHN TROHA, SOMERVILLE FAMILY PRACTICE, VIRGINIA Contents Preface 5 Acknowledgments 6 List of Exhibits 7 Executive Summary 8 Introduction 22 Access 26 Prevention and Treatment 31 Potentially Avoidable Use of Hospitals and Costs of Care 37 Equity 45 Healthy Lives 51 Cross-Cutting Findings 57 Impact of Improved Performance 60 Aiming Higher: The Need for Action to Improve Performance 62 Conclusion 66 Notes 67 Appendices 70 About the Authors 104 Further Reading 105 PHOTO: CORBIS Preface T he Commonwealth Fund Commission on a The scorecard findings of deteriorating coverage High Performance Health System is pleased and rising costs, combined with broad geographic to sponsor the 2009 State Scorecard on disparities, point to the need for national reforms as Health System Performance. The second edition of well as state action. In addition, widespread evidence the State Scorecard, first published in 2007, provides of poorly coordinated care poses a challenge to all current information and trends on states’ progress states to seek delivery system reforms that integrate toward achieving systems and models of health care care across providers. that meet their residents’ needs. Evidence that federal expansions of coverage for Building on the first edition and the National children have made a difference across the country Scorecard on U.S. Health System Performance, the highlights the potential of reforms that seek to insure 2009 State Scorecard examines variation across the more adults. Federal efforts to provide public in- states on key indicators of health care access, preven- formation on quality of care have also enabled and tion and treatment, potentially avoidable hospital use stimulated improvement across states. The 2009 State and costs, and population health. By enabling states Scorecard points to the potential for rapid change, to compare themselves with others on critical aspects especially when information on improvement is of their health care systems, we hope to motivate the available to support local efforts. development of strategies and action toward higher All states face the problem of how to slow the performance across the entire nation. growth in costs while improving value and outcomes The 2009 update echoes the troubling conclusion and securing access. Doing better is within our grasp. of the first State Scorecard—that when it comes to Ensuring access to high-quality, equitable care— access to care when you need it, the quality of care regardless of where you live—will require a commit- you receive, and the likelihood of living a healthier ment to aim higher on all levels, as well as national life, where you live matters. Wide variations in care and state reforms and actions. and outcomes persist, with top-performing states continuing to surpass their peers on multiple di- James J. Mongan, M.D. Stephen C. Schoenbaum, M.D. Chairman Executive Director mensions. Moreover, the state leaders have set new, higher benchmarks on many indicators. These gains The Commonwealth Fund Commission on underscore opportunities to improve. Yet, even the a High Performance Health System top states are not performing as well as they could in certain areas. 5 Acknowledgments T he authors would like to thank the members Abuse and Mental Health Services Administration’s of the Commonwealth Fund Commission Office of Applied Studies produced the state-level on a High Performance Health System for data on treatment of depression. Christina Bethell, their invaluable guidance. We also owe our sincere Ph.D., M.P.H., M.B.A., and Scott Stumbo, M.A., at the appreciation to all of the researchers who developed Child and Adolescent Health Measurement Initiative indicators and conducted data analyses to update assisted us in interpreting data from the National the State Scorecard. We particularly thank Katherine Survey of Children’s Health. Hempstead, Ph.D., Rutgers University Center for State Three members of the Commission reviewed Health Policy, for estimates of mortality amenable to the State Scorecard methodology and drafts of the health care, with variation by race, for all 50 states report. We especially thank Patricia Gabow, M.D., and the District of Columbia. Gerard Anderson, chief executive officer, Denver Health, Sandra Ph.D., and Robert Herbert, at the Johns Hopkins Shewry, M.P.H., M.S.W., president and chief executive University Bloomberg School of Public Health, officer, California Center for Connected Health, and provided analysis of data on potentially preventable Alan Weil, J.D., M.P.P., executive director, National hospital admissions of Medicare patients, as well as Academy for State Health Policy. Additionally, we 30-day hospital readmissions; Paul Fronstin, Ph.D., thank Ernest Moy, M.D., M.P.H., medical officer, at the Employee Benefit Research Institute, provided Center for Quality Improvement and Patient Safety analysis of uninsured rates derived from the Current at the Agency for Healthcare Research and Quality Population Survey; Vincent Mor, Ph.D., and Zhanlian for assistance with data updates and review. Feng, Ph.D., at Brown University’s Department of We’d also like to thank the following Common- Community Health, provided the analysis of nursing wealth Fund staff: Karen Davis and Stephen Schoen- home admission and readmission rates; and Melissa baum for reviewing drafts; and the Fund’s communi- Singh, M.A., and Ti-Kuang Lee at IPRO, provided cations team, including Barry Scholl, Chris Hollander, analysis of CMS Hospital Compare quality data. Martha Hostetter, Mary Mahon, Christine Haran, Bisundev Mahato and Nicholas Tilipman, Columbia Suzanne Barker Augustyn, and Paul Frame, for their University Mailman School of Public Health, provided guidance, editorial and production support, and public programming and analytical support. Elliott Fisher, dissemination efforts. Finally, we thank Margaret M.D., M.P.H., and Kristen Bronner, M.A., at the Koller, M.S., of the Rutgers Center for State Health Dartmouth Institute for Health Policy and Clinical Policy, for her work overseeing the production of the Practice provided analysis of the Dartmouth Atlas State Scorecard; Kimberly Mueller, M.S., formerly of Hospital Care Intensity Index; David Goodman, Issues Research, Inc., Manisha Agrawal, M.P.H., of the M.D., M.S., at the Dartmouth Institute provided data Rutgers Center for State Health Policy, and Deborah on hospice use among Medicare cancer patients in Chase, M.P.A., for their research assistance; and Jim cooperation with the American Cancer Society. James Walden of Walden Creative for working with us to Colliver, Ph.D., and Art Hughes at the Substance design and produce the final report. 6 List of Exhibits E x hibit 1 State Scorecard Summary of Health System Performance Across Dimensions E x hibit 2 List of 38 Indicators in State Scorecard on Health System Performance E x hibit 3 2009 Scorecard Compared with 2007 Scorecard: Summary of State Performance on Indicators with Trends E x hibit 4 Medicare Cost Per Beneficiary and 30-Day Readmissions by State E x hibit 5 Average Employer Premiums as Percentage of Median Household Income for Under-65 Population, Distribution by State E x hibit 6 State Ranking on Health System Performance by Dimension Access E x hibit 7 State Ranking on Access Dimension E x hibit 8 Percent of Adults Ages 18–64 Uninsured by State from 1999–2000 to 2007–08 E x hibit 9 Percent of Children Ages 0–17 Uninsured by State from 1999–2000 to 2007–08 E x hibit 1 0 Percent of Adults and Children Uninsured by State, 2007–08 E x hibit 1 1 State Ranking on Access and Prevention/Treatment Dimensions Prevention and Treatment E x hibit 1 2 State Ranking on Prevention and Treatment Dimension E x hibit 1 3 State Variation: Ambulatory Care Quality Indicators E x hibit 1 4 State Variation: Hospital Care Quality Indicators E x hibit 1 5 State Variation: Prevention of Surgical Complications E x hibit 1 6 State Variation: Coordination of Care Indicators E x hibit 1 7 State Variation: Hospital Discharge Planning Potentially Avoidable Use of Hospitals and Costs of Care E x hibit 1 8 State Ranking on Potentially Avoidable Use of Hospitals and Costs of Care Dimension E x hibit 1 9 State Rates of Hospital Admissions for Ambulatory Care Sensitive Conditions Among Medicare Beneficiaries E x hibit 2 0 State Variation: Hospital Admissions Indicators E x hibit 2 1 State Variation: Hospital Care Intensity Index E x hibit 2 2 Median Income, Health Insurance Premiums as Percent of Income, and Percent of Nonelderly Adults Uninsured by State Equity E x hibit 2 3 Summary of Changes in Equity Dimension E x hibit 2 4 Equity Dimension and Equity Type Ranking E x hibit 2 5 Lack of Recommended Preventive Care by Income and Insurance E x hibit 2 6 Children Without a Medical Home by Income and Insurance E x hibit 2 7 Prevention/Treatment and Access Indicators by Race/Ethnicity, National Averages Healthy Lives E x hibit 2 8 State Ranking on Healthy Lives Dimension E x hibit 2 9 Mortality Amenable to Health Care by State E x hibit 3 0 Mortality Amenable to Health Care by Race, National Average and State Variation E x hibit 3 1 Preventable Mortality and Uninsured Rates Among Whites, by State E x hibit 3 2 National Cumulative Impact If All States Achieved Top State Rate 7 Executive Summary T he 2009 edition of The Commonwealth Fund’s the uninsured and establish a “blueprint for health” State Scorecard on Health System Performance focused on preventing and controlling chronic disease finds deteriorating health insurance coverage are providing a new model for other states. for adults and rising health care costs, but also Thirteen states—Vermont, Hawaii, Iowa, improved quality of care on dimensions of perfor- Minnesota, Maine, New Hampshire, Massachusetts, mance that have been the focus of public reporting Connecticut, North Dakota, Wisconsin, Rhode and incentive programs. As reported in the inaugural Island, South Dakota, and Nebraska—again rise to State Scorecard in 2007, where you live within the the top quartile of the overall performance rankings, United States makes a difference in your access outperforming their peers on multiple indicators to care, quality of care, and experiences with care (Exhibit 1). Conversely, states in the lowest quartile providers. The findings of this report point to the often lag the leaders in multiple areas. The persis- urgency of comprehensive national health system tent wide geographic variation points to the need for reforms aimed at improving health system perfor- national reforms to ensure high performance across mance across the country, eliminating disparities, the country. and enhancing and assisting states’ efforts to address Following are some of the cross-cutting state population health needs and ensure affordable access. findings and key trends gleaned from analysis of the With a central focus on identifying opportunities to scorecard results: improve, the State Scorecard provides a framework for state and federal action to address common concerns • Since the beginning of the decade, insurance as well as specific areas of need. It assesses states’ coverage in most states has been eroding for performance relative to what is achievable, based on adults while increasing or holding steady for benchmarks for 38 indicators of access, quality, costs, children. This divergence reflects the impact of and health outcomes. The findings highlight continued federal action to expand coverage for children wide variability in performance across states. But they through the Children’s Health Insurance Program also show that all states face challenges posed by rising (CHIP); rates of uninsured children in 2008 were costs of care and poor care coordination. Although the lowest since 1987. Nevertheless, high and rising the scorecard does not yet reflect the impact of the rates of uninsured adults in many states under- economic downturn—given the two- to three-year score the need for comprehensive national reform time lag in data reporting—the deterioration seen in to expand coverage in all states, and to further the access to care across the country underscores the need gains made in Massachusetts, Vermont, and other for coherent reforms that would change the trajectory states that have taken a lead in enacting reforms. of costs, ensure access, and enhance value. • The quality of hospital care for heart attack, heart Overall, the 2009 State Scorecard paints a picture of health care systems under stress. Still, improvements failure, pneumonia, and the prevention of surgical made in certain indicators and in certain areas of the complications improved dramatically, as all states U.S. indicate that individual states have the capacity gained ground and the variation across states to do much better, especially when their efforts are narrowed. This improvement reflects the impact supported by strong federal policy and national initia- of national efforts by Medicare to measure and tives. In 2009, Vermont, Hawaii, Iowa, Minnesota, benchmark performance. Maine, and New Hampshire lead the nation as the • Key indicators of nursing home and home health top-ranked states (Hawaii and Iowa tied for second care quality improved substantially in nearly all place; Maine and New Hampshire tied for fifth). states, with declines in rates of pressure ulcers, Their performance ranks in the top quartile of states physical restraints, and pain for nursing home on a majority of scorecard indicators. In particular, residents and improved mobility for home care the reforms passed by Vermont in 2006 to cover patients. Notably, these long-term care quality 8 EXECUTIVE SUMMARY EXHIBIT 1 State Scorecard Summary of Health System Performance Across Dimensions State Rank Top Quartile ts ts os os Second Quartile dC dC t t an an en en Third Quartile se se tm tm Bottom Quartile lU lU rea rea it a it a dT dT sp sp an an Ho Ho 2009 Ranking Revised 2007 Ranking* es es Li v Li v on on le le nt i nt i ab ab hy hy ss ss y y oid oid ve ve alt alt uit uit ce ce Pr e Pr e He He Av Av Eq Eq Ac Ac RANK S TAT E RANK S TAT E 1 Vermont 1 Hawaii 2 Hawaii 2 Vermont 2 Iowa 3 Iowa 4 Minnesota 4 Connecticut 5 Maine 5 New Hampshire 5 New Hampshire 6 Massachusetts 7 Massachusetts 7 Maine 8 Connecticut 8 Rhode Island 9 North Dakota 9 Minnesota 10 Wisconsin 10 Nebraska 11 Rhode Island 11 Wisconsin 12 South Dakota 12 North Dakota 13 Nebraska 13 South Dakota 14 Delaware 14 Pennsylvania 15 Pennsylvania 15 Washington 16 Washington 16 Maryland 17 Maryland 17 Michigan 18 Montana 18 Kansas 19 Utah 19 Delaware 20 Michigan 20 Montana 21 New York 21 Wyoming 22 Virginia 22 New Jersey 23 Kansas 23 Colorado 24 Colorado 24 Utah 25 Wyoming 24 Virginia 26 District of Columbia 26 Ohio 27 Ohio 27 New York 28 Indiana 28 District of Columbia 29 Idaho 29 Idaho 30 New Jersey 30 North Carolina 31 California 31 Missouri 32 Oregon 32 Illinois 33 South Carolina 33 Arizona 34 Alaska 34 Alaska 35 West Virginia 35 Oregon 36 Arizona 35 New Mexico 36 Missouri 35 South Carolina 38 Georgia 38 Indiana 39 Tennessee 39 Alabama 40 Alabama 40 California 41 North Carolina 41 Tennessee 42 Illinois 42 West Virginia 42 New Mexico 43 Kentucky 44 Florida 44 Georgia 45 Kentucky 45 Florida 46 Texas 46 Louisiana 47 Nevada 47 Nevada 48 Arkansas 48 Texas 49 Louisiana 49 Arkansas 50 Oklahoma 50 Oklahoma 51 Mississippi 51 Mississippi * Some state rates from the 2007 edition have been revised to match methodology used in the 2009 edition. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 9 metrics have also been the focus of public report- Dakota, and Nebraska—again rise to the top quartile ing and collaborative improvement initiatives. of the overall performance rankings (Exhibit 1). • Ambulatory care quality indicators, including Though specific rankings shifted, these are the same preventive care, changed little or declined in half group of states identified as top performers in the first the states, with wide gaps persisting across states. State Scorecard two years ago. Many have been leaders • In a majority of states, symptoms of poor care in reforming and improving their health systems— coordination and continued inefficiency in the use for example, by targeting efforts to reduce rates of of resources are evident in the increasing rates of uninsured adults and children. hospital readmissions. And in most states, there Ten of the 13 states in the lowest quartile of per- have also been increases in hospital admissions formance—Tennessee, Alabama, Florida, Kentucky, and readmissions from nursing homes, as well as Texas, Nevada, Arkansas, Louisiana, Oklahoma, and hospital admissions for home health care patients. Mississippi—also ranked in the bottom quartile These indicators point to a lack of incentives for in the 2007 State Scorecard. Three others—North effective transitional care and care management. Carolina, Illinois, and New Mexico—dropped from • States with the highest readmission rates also the third quartile, while California, West Virginia, tended to have the highest costs of care overall— and Georgia moved up out of the last quartile. The signaling a need for a systematic approach to ad- 13 states in the lowest quartile lagged well behind dressing cost concerns. their peers on indicators across dimensions of per- • Rising costs are making care and coverage less formance. Rates of uninsured adults and children are, affordable for a growing share of families. Across on average, double those in the top quartile of states. the country, insurance premiums are rising faster Receipt of recommended preventive care is generally than middle-class family incomes. lower, and mortality from conditions amenable to • Differences in how well the health care system health care is, on average, 50 percent higher in these functions for people based on their income level, states than in leading states. health insurance status, and race/ethnicity—what Among the states that moved up the most in the is referred to here as the “equity gap”—were more overall performance rankings, Minnesota rose within likely to widen than narrow. the top quartile to become the fourth-ranked state, with significant improvement on multiple indica- Distinct regional patterns and sharp differences tors. In three states—Arkansas, Delaware, and West in performance across states—with some persistent Virginia—plus the District of Columbia, at least half gaps even in the best-performing states—attest to of the performance indicators improved by 5 percent the reality that our health care system fails to provide or more. Leading states set new benchmarks for 20 reliable access to the affordable, effective, patient- of the 35 indicators with trends. centered, coordinated care that everyone should These patterns indicate that public policies, expect, given the large and growing share of the plus state and local health care systems, can make nation’s economic resources that are invested in the a difference. Vermont, Maine, and Massachusetts, health care sector. for example, have enacted comprehensive reforms to expand coverage and put in place initiatives to Highlights and improve population health and benchmark providers C r o s s - C u tt i n g T h e m e s on quality. Minnesota is a leader in bringing public- Leading states consistently outperform and private-sector stakeholders together in collabora- lagging states across indicators and dimen- tive initiatives to improve the overall value of health sions; public policy and public–private care—an approach that is gaining traction in other collaboration can make a difference. states. As New York and Utah have made concerted Thirteen states—Vermont, Hawaii, Iowa, Minnesota, efforts to improve their performance in priority Maine, New Hampshire, Massachusetts, Connecticut, areas, these states’ performance on key indicators North Dakota, Wisconsin, Rhode Island, South has improved. Yet socioeconomic factors also play a 10 role. Many of the states that ranked low on multiple • At least $5 billion would be saved from avoiding performance indicators have high levels of poverty, preventable hospitalizations and readmissions making it difficult to provide affordable coverage for chronically ill or frail elderly nursing home without federal action. patients. • Savings of $20 billion to $37 billion per year would Wide variations in access, quality, costs, and be possible if annual per-person costs for Medicare health outcomes persist across states. in higher-cost states fell to the median state rate Overall, the range of performance remains wide or to the average rate achieved in the top quartile across states and across dimensions of performance, of states. with a two-to-three-fold spread between top- and bottom-performing states on multiple indicators Geographic variations remain striking, repeating (Exhibit 2). On many indicators, the leading states the same general patterns seen in the first State have improved substantially since the 2007 State Scorecard. States in the Upper Midwest and New Scorecard—setting new benchmarks. England continue to lead, and states across the South, The divergence in performance is particularly the Southwest, and the Lower Midwest continue to wide when it comes to the following indicators: per- trail those in other regions on overall performance centage of insured; diabetic patients receiving recom- rankings. This pattern generally holds for the access, mended care; mental health care for children; pres- quality, and equity dimensions, though western states sure ulcers in nursing homes; preventable hospital tend to perform better on avoidable hospital use and admissions; and mortality amenable to health care. costs of care and on the “healthy lives” dimensions To reach the level of top-performing states, bottom- (Exhibit 1). Yet exceptions also exist, especially where states and care systems have made a concerted effort performing states would need to improve by an aver- to improve. age of 40 to 50 percent. Improving the performance of all states to the Improvements in key areas of health levels achieved by the best states could save thousands care quality are promising. of lives, improve access and quality of life for millions The State Scorecard also documents widespread im- of people, and reduce costs. In turn, this would free provement across states on selected indicators, es- up funds to pay for improved care and expanded pecially quality indicators for which there has been insurance coverage—producing a net gain in value a national commitment to reporting performance from a higher-performing health care system. If all data and collaborative efforts to improve. Notably, states could match benchmarks set by the top-per- for some indicators of hospital clinical processes, the forming state, the cumulative effect would mean: average performance of the bottom-ranked states now exceeds the median state rate of three years ago, • Nearly 78,000 fewer adults and children would with virtually all states improving (Exhibits 2 and 3). die prematurely (before age 75) each year from These indicators include treatment for heart attack, conditions amenable to health care. heart failure and pneumonia, prevention of surgical • The number of people without health coverage complications, and provision of written discharge would be more than halved, with 29 million more instructions for heart failure patients. people insured. Publicly reported quality measures related to the • Nine million more adults (age 50 and older) delivery of patient-centered care in nursing homes would receive all recommended preventive care, also improved substantially across states. The average and almost 800,000 more young children would state performance on reported pain and use of receive key vaccinations on time. physical restraints on residents improved by at least • Four million more diabetic patients across the 5 percent in all states, and in the majority of states nation would receive basic services to help avoid average performance improved by the same amount complications such as blindness, kidney failure, for a measure of pressure ulcers; the range of per- or limb amputation. formance between states narrowed as well. One key 11 eXeCuTiVe summary ExHIBIT 2 List of 38 Indicators in State Scorecard on Health System Performance Range of State Performance (Bottom State Rate– All States Median Top State Rate) Best State Revised 2007 Revised 2007 2009 2009 Access Scorecarda 2009 Scorecard Scorecarda Scorecard Scorecard 1 Nonelderly adults (ages 18–64) insured 82.4 82.2 70.4–89.6 68.5–92.8 MA 2 Children (ages 0–17) insured 91.5 91.4 80.2–95.4 80.4–96.8 MA 3 At-risk adults visited a doctor for routine 87.0 84.1 79.1–94.2 75.0–93.0 RI checkup in the past two years 4 Adults without a time in the past year when they 87.6 87.5 80.8–93.7 80.7–93.1 HI needed to see a doctor but could not because of cost Prevention & Treatment 5 Adults age 50 and older received recommended 39.7 42.4 32.6–50.1 35.0–52.5 DE screening and preventive care 6 Adult diabetics received recommended preventive care 44.4 44.8 28.7–62.4 33.3–66.9 MN 7 Children ages 19–35 months received all 81.6 80.1 66.7–93.5 66.7–93.2 NH recommended doses of five key vaccines 8 Children with both a medical and dental —b 71.0 —b 60.2–85.3 RI preventive care visit in the past yearb 9 Children who received needed mental 61.9 63.0 43.4–77.2 41.7–81.5 PA health care in the past year 10 Hospitalized patients received recommended care 84.4 91.6 78.4–88.4 84.9–95.6 NH & ND for heart attack, heart failure, and pneumonia 11 Surgical patients received appropriate 70.5 85.3 50.7–90.0 78.3–92.7 ME care to prevent complications 12 Home health patients who get better 36.2 40.5 31.4–41.8 33.8–48.2 UT at walking or moving around 13 Adults with a usual source of care 81.5 81.8 65.6–89.0 69.2–89.0 DE & PA 14 Children with a medical homeb —b 60.7 —b 45.4–69.3 NH 15 Heart failure patients given written instructions at discharge 50.6 75.1 14.2–84.1 53.8–91.4 SD 16 Medicare patients whose health care provider always listens, 68.7 74.5 63.1–74.9 68.7–78.0 DE explains, shows respect, and spends enough time with them 17 Medicare patients giving a best rating for 70.2 61.1 61.2–74.4 54.0–69.3 DE health care received in the past year 18 High-risk nursing home residents with pressure sores 13.2 11.5 19.3–7.6 17.2–7.5 ND & MT 19 Long-stay nursing home residents who 6.2 4.0 15.9–1.9 11.0–1.5 DE & NE were physically restrained 20 Long-stay nursing home residents who 6.3 4.2 11.4–1.6 8.2–0.9 DC have moderate to severe pain Avoidable Hospital Use & Costs 21 Hospital admissions for pediatric asthma per 100,000 children 152.6 125.5 289.5–55.0 253.5–48.6 OR 22 Adult asthmatics with an emergency room 16.3 —c 29.7–10.8 —c UT or urgent care visit in the past yearc 23 Medicare hospital admissions for ambulatory care 6,845 6,291 10,548–4,214 9,331–3,725 UT sensitive conditions per 100,000 beneficiaries 24 Medicare 30-day hospital readmissions 17.1 17.5 22.6–12.9 22.7–12.9 OR as a percent of admissions 25 Long-stay nursing home residents with a hospital admission 16.6 18.7 29.4–7.2 31.4–6.9 MN 26 Short-stay nursing home residents with 18.2 20.8 26.5–12.4 26.8–13.2 UT hospital readmission within 30 days 27 Home health patients with a hospital admission 26.9 28.7 46.4–18.3 43.3–21.2 UT 28 Hospital Care Intensity Index, Based on inpatient days and inpatient visits among chronically ill 0.959 0.958 1.565–0.495 1.548–0.509 UT Medicare beneficiaries in last two years of life 29 Total single premium per enrolled employee at private- $4,379– $5,293– $3,706 $4,360 ND sector establishments that offer health insurance $3,034 $3,830 30 Total Medicare (Parts A & B) reimbursements per enrollee $8,565– $9,564– $6,371 $7,698 HI $4,778 $5,311 Healthy Lives 31 Mortality amenable to health care, 95.6 89.9 174.2–71.6 158.3–63.9 MN deaths per 100,000 population 32 Infant mortality, deaths per 1,000 live births 7.1 6.8 11.0–4.3 13.7–4.5 UT 33 Breast cancer deaths per 100,000 female population 25.3 23.7 34.1–16.2 29.8–17.7 AK 34 Colorectal cancer deaths per 100,000 population 20.0 17.8 24.6–15.3 21.1–13.3 UT 35 Suicide deaths per 100,000 population 11.7 11.8 21.8–5.9 21.5–5.5 DC 36 Nonelderly adults (ages 18–64) limited in any activities 15.7 17.0 23.8–10.2 24.0–12.0 ND because of physical, mental, or emotional problems 37 Adults who smoke 21.4 20.1 29.0–11.2 28.3–10.7 UT 38 Children ages 10–17 who are overweight or obese 29.9 30.6 39.5–20.8 44.5–23.1 MN & UT a Some state rates from the 2007 edition have been revised to match methodology used in the 2009 edition. See methodology on p. 25 for further details. b Previous year data not shown; data are not comparable over two time periods because of changes in survey design. c Data not updated; data presented here are used for both past and current ranking. Notes: All values are expressed as percentages unless labeled otherwise. See Appendix B for data year, source, and definition of each indicator. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 12 measure of home health care quality—improvement Making continual improvement the norm across in patients’ mobility—also showed a 5-percent-or- all performance indicators and in all states will require greater improvement in most states. national as well as state policies that ensure access to Currently, all hospitals are required to publicly care, realign incentives, set targets, and make available report selected quality indicators in return for the information needed to effect change. Robust payment updates from Medicare. Several public and measures of outcomes are needed as well to drive private initiatives have further tied payment incen- transformative system change; “process” indicators tives to hospitals’ improvement on such metrics. The alone are not enough. It is also clear that improving rapid improvement in a relatively short time illus- care one disease or process at a time will not be an trates the importance of data in guiding and driving effective approach to achieving high performance change, as well as the necessity of having incentives across the board. in place to foster higher performance. In contrast, Symptoms of poor care coordination and inef- hospital readmission rates and several quality indi- ficient or suboptimal use of resources point to cators that generally are not publicly available at the opportunities to improve both quality and cost. delivery-system level failed to improve or evidenced mixed performance across states. The State Scorecard points to evidence of gaps in A general trend toward lower rates of mortality care and fragmented care that reflects health system amenable to health care, cancer deaths, and smoking dysfunction: the failure to provide timely and effec- is also promising, although most states’ death tive preventive and chronic care; high and, in many rates substantially exceed rates achieved by the states, increasing hospital readmission rates; and ris- benchmark states. ing hospitalization rates for nursing home residents Unfortunately, these large gains were not and home health care patients across most states. matched in other areas. For example, there were Despite improvement, rates of potentially preventable only modest improvements seen in preventive care hospitalizations remain relatively high in many states. for adults—and in only half the states. The majority And the gaps in receipt of recommended preventive of states failed to improve on multiple indicators of care such as cancer screenings and immunizations ambulatory care quality and access over the two- across states underscore the need for a stronger pri- to-four-year trends typically captured by the 2007 mary care infrastructure in the United States. and 2009 scorecards. Many indicators of avoidable Annual costs of health care (average employer- hospital use and costs of care failed to improve or group premiums for individuals and Medicare grew worse, especially hospital admissions and spending per beneficiary) vary widely across states, readmissions from nursing homes—highlighting with no apparent systematic relationship to insurance the need for better coordination of care across care coverage or ability to pay (as measured by median settings. It should be noted that the data related to income). Moreover, across states there is no sys- access to care reflect the period prior to the current tematic relationship between scorecard indicators economic recession, which has likely worsened of the cost and quality of care across states. Some access for adults. Similarly, the data predate the states in the Upper Midwest (e.g., Iowa, Minnesota, extension of CHIP, which may be helping to offset Nebraska, North Dakota, and South Dakota) achieve the recession’s impact on children. high quality at lower costs. Although these states are On 20 of 35 indicators for which trend data are exceptions to the rule, they provide examples for available, the median state rate (representing the other states to follow in pursuit of both goals. middle of the range) failed to improve or declined States with higher medical costs tend to have by 5 percent or more. Only 15 indicators improved higher rates of potentially preventable hospital use, by 5 percent or more, mainly in the quality domain including high rates of readmission within 30 days of (Exhibit A2). Disturbingly, the range of performance discharge (Exhibit 4) and high rates of admission for across states widened on a third of indicators—often complications of diabetes, asthma, and other chronic in tandem with a decline across states. conditions. Reducing the use of expensive hospital 13 eXeCuTiVe summary ExHIBIT 3 2009 Scorecard Compared with 2007 Scorecard: Summary of State Performance on Indicators with Trends No Change State Rate State Rate or Less Number of No Change Improved Worsened than 5% states with State Rate State Rate in State by 5% or by 5% or Change in Access trends Improved Worsened Rate More More State Rate Nonelderly adults (ages 18–64) insured 51 20 31 0 2 1 48 Children (ages 0–17) insured 51 28 21 2 0 0 51 At-risk adults visited a doctor for routine 51 8 42 1 0 15 36 checkup in the past two years Adults without a time in the past year when they needed 51 23 25 3 0 0 51 to see a doctor but could not because of cost Prevention & Treatment Adults age 50 and older received recommended 51 48 3 0 26 1 24 screening and preventive care Adult diabetics received recommended preventive care 42 26 15 1 18 6 18 Children ages 19–35 months received all 51 20 30 1 9 10 32 recommended doses of five key vaccines Children who received needed mental health care in the past year 51 27 24 0 21 12 18 Hospitalized patients received recommended care 51 51 0 0 48 0 3 for heart attack, heart failure, and pneumonia Surgical patients received appropriate care to prevent complications 51 50 1 0 49 0 2 Home health patients who get better at walking or moving around 51 50 1 0 43 1 7 Adults with a usual source of care 51 31 16 4 3 0 48 Heart failure patients given written instructions at discharge 51 51 0 0 51 0 0 Medicare patients whose health care provider always listens, 50 48 2 0 41 0 9 explains, shows respect, and spends enough time with them Medicare patients giving a best rating for 50 1 49 0 0 46 4 health care received in the past year High-risk nursing home residents with pressure sores 51 47 3 1 38 1 12 Long-stay nursing home residents who were physically restrained 51 51 0 0 51 0 0 Long-stay nursing home residents who 51 51 0 0 51 0 0 have moderate to severe pain Avoidable Hospital Use & Costs Hospital admissions for pediatric asthma per 100,000 children 32 26 6 0 24 5 3 Medicare hospital admissions for ambulatory care 51 48 3 0 36 2 13 sensitive conditions per 100,000 beneficiaries Medicare 30-day hospital readmissions as a percent of admissions 51 17 32 2 5 16 30 Long-stay nursing home residents with a hospital admission 48 8 39 1 3 29 16 Short-stay nursing home residents with 48 3 44 1 1 37 10 hospital readmission within 30 days Home health patients with a hospital admission 51 13 38 0 5 27 19 Hospital Care Intensity Index, Based on inpatient days and inpatient visits among chronically ill 51 27 23 1 7 3 41 Medicare beneficiaries in last two years of life Total single premium per enrolled employee at private- 51 0 51 0 0 50 1 sector establishments that offer health insurance Total Medicare (Parts A & B) reimbursements per enrollee 51 0 51 0 0 51 0 Healthy Lives Mortality amenable to health care, deaths per 100,000 population 51 50 1 0 45 0 6 Infant mortality, deaths per 1,000 live births 51 28 22 1 14 11 26 Breast cancer deaths per 100,000 female population 51 41 10 0 27 5 19 Colorectal cancer deaths per 100,000 population 51 47 4 0 44 0 7 Suicide deaths per 100,000 population 51 23 26 2 14 18 19 Nonelderly adults (ages 18–64) limited in any activities 51 8 42 1 1 33 17 because of physical, mental, or emotional problems Adults who smoke 51 49 1 1 40 0 11 Children ages 10–17 who are overweight or obese 51 18 33 0 9 20 22 Note: Three indicators are excluded because data do not allow assessment of trends: children with medical and dental preventive care visits, children with a medical home, and adult asthmatics with emergency room visit. See Appendix B for the two time periods covered for each indicator. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 14 EXECUTIVE SUMMARY EXHIBIT 4 Medicare Cost Per Beneficiary and 30-Day Readmissions by State $10,000 NY NJ $9,500 FL LA MA TX CT MD $9,000 Medicare reimbursement per enrollee CA NV MI OK RI $8,500 IL OH TN PA KY $8,000 NH AL MS AZ WV SC MO DE CO AK GA IN DC KS AR $7,500 NC VT WA ME $7,000 UT NE WI VA NM MN $6.500 ID IA WY MT SD OR ND R2 = 0.40 $6,000 $5,500 HI $5,000 10 15 20 25 Medicare 30-day readmissions as percent of admissions DATA: Medicare readmissions—2006–07 Medicare 5% SAF Data; Medicare reimbursement—2006 Dartmouth Atlas of Health Care SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 care by preventing complications, controlling chronic This upward pressure on the cost of health coverage conditions, and providing effective transitional care has led to erosion in the generosity of insurance following discharge has the potential to improve benefits, which in turn has increased the number outcomes and lower costs. of “underinsured” individuals and caused others to lose their coverage entirely. Reversing these trends Affordability is a growing will require a dual focus on “bending the cost curve” concern throughout the states. as well as action to secure affordable coverage for all. In most states, health insurance premiums have been rising faster than household incomes. Using There is room for improvement across all states. average employer-sponsored insurance premiums All states have substantial room to improve. No state (including the employee share) for individual em- ranked in the top quartile across all performance ployees as a proxy for average insurance costs in indicators. On some indicators, even the top rates each state, the State Scorecard finds that by 2008, are well below what should be achievable. In each of average premiums amounted to 16 percent or more the states with the highest overall rankings, several of median household income in 37 states, compared indicators declined by 5 percent or more; each also with 16 states five years earlier (Exhibit 5). In 18 had some indicators in the bottom quartile or half of states, premiums amounted to 18 percent or more performance. At the same time, in each of the lowest- of median income for the under-65 population. By ranked states, there were certain areas of performance 2008, only three states (Colorado, New Jersey, and that improved—some quite significantly. Maryland) had premiums averaging under 14 per- While leading states such as Massachusetts, cent of median income. Minnesota, and Vermont have enacted policy reforms 15 EXECUTIVE SUMMARY EXHIBIT 5 Average Employer Premiums as Percentage of Median Household Income for Under-65 Population, Distribution by State, 2003 and 2008 Number of states with premiums amounting to following percentages of income 30 2003 2008 22 20 19 18 13 13 11 10 3 3 0 Less than 14% 14.0%–15.9% 16.0%–17.9% 18% or more DATA: Average premiums for employer-based health insurance plans (weighted by single and family household distribution)—2003 and 2008 Medical Expenditure Panel Survey; Median household incomes for under-65 population—2004–05 and 2008 Current Population Survey ASEC Supplement (representing 2003–04 and 2007 data). SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 that are extending coverage, promoting community uninsured rates (16% or more) declined from health, and building value-based purchasing strat- nine to three during this time, reflecting federal egies through public–private collaboration, this support of CHIP. has not been the case in the vast majority of states. • From 2004–05 to 2007–08—the time span rep- Encouraging the adoption of systemic improvements resented in the State Scorecard’s coverage indica- will likely require Medicare’s participation in state tors—trends in coverage were negative in most payment initiatives and will require collaborative states for adults and in two of five states for children federal and state efforts to develop the information (Exhibit 3). That this was true even before the and shared resources infrastructure necessary to severe recession underscores the challenge that achieve high performance. states face in ensuring coverage for children and adults in the absence of federal action. K EY F INDINGS AND S TAT E VARIAT IONS , BY DIMENSION o f p e r f o r m a n c e • Massachusetts, which had only begun to imple- ment its universal health insurance program Access during the period covered by the State Scorecard, • For the most part, performance on the State had the greatest increase in coverage for adults Scorecard’s health care access indicators failed to and made gains in coverage for children between improve from 2003 to 2008. Gaps in health insur- 2004–05 and 2007–08, becoming the top-ranked ance coverage between the top and bottom states state for the coverage of both adults and children remained wide, with uninsured rates for children as well as the top-ranked state for access to ranging from 3 percent to 20 percent and rates for adults ranging from 7 percent to over 30 percent. care overall. • Since the start of the decade—from 1999–2000 to • Across states, the percentage of adults who reported 2007–08—the number of states with high unin- going without health care because of the cost is sured rates (23% or higher) for nonelderly adults closely associated with insurance coverage and is rose from two to nine, while the number with up to three times greater in states with the highest low rates (under 14%) dropped from 22 to 11. In uninsured adult rates than in states with the lowest contrast, the number of states with high children’s uninsured adult rates (19% vs. 7%). 16 Prevention and Treatment of children who received effective, patient-centered • Almost all states improved on process indica- care coordination from a primary care medical tors of the quality of hospital treatment (48 states home ranged from more than two-thirds (69%) in by 5% or better) and nursing home care (38 to 51 New Hampshire to less than half (45%) in Nevada. states by 5% or better across three indicators). On • Across all states in 2007, there was a divergence a set of hospital clinical quality measures, the rate in how Medicare patients rated their care, with in the five lowest-performing states in 2007 had provider interactions rated more highly and overall risen to the level of the five highest-performing care experience rated more poorly than in 2003. states three years earlier. On an expanded set of (These trends should be interpreted with caution, measures to prevent surgical complications in however, because of changes in survey administra- hospitals, the variation in performance among tion.) More data are needed to judge whether these states narrowed by half. shifts are an anomaly or represent an enduring • Despite a 30 percent narrowing in state variation change in patients’ experiences. on nursing home care, the range has remained wide, with a two-to-five-fold variation between Potentially Avoidable Use the top-five and bottom-five states. of Hospitals and Costs of Care • States have failed to match these gains when it • Hospital admissions among Medicare beneficiaries comes to the quality of ambulatory care; even in for ambulatory care sensitive conditions improved the best states, quality continues to be well below (i.e., declined) in a majority of states, although standards. The percentage of adults age 50 and rates fluctuated from year to year—illustrating older receiving all recommended cancer screen- the importance of looking at long-term trends ings and immunizations ranged from a high of when assessing improvement. Declining hospital just 53 percent in Delaware to a low of 35 percent admissions may reflect patients’ improved access in Oklahoma. Only about half the states improved to medications for chronic conditions, or incen- by 5 percent or more. The proportion of diabetic tives provided to manage such conditions better. patients receiving three basic services to prevent (The way hospital administrators code diseases disease complications varied from two-thirds in for reimbursement purposes also has changed, Minnesota to one-third in Mississippi. The rate potentially influencing trends for some conditions.) worsened or failed to improve significantly in 24 • Hospitalization rates for pediatric asthma declined of 42 states for which data were available. across most of the 32 states that reported data in • More than one-quarter of young children in the both time periods. Yet despite some narrowing in bottom-five states did not receive timely preventive state variation, rates were three times greater in the medical and dental visits and recommended vac- highest-rate states compared with the lowest-rate cinations, and in the bottom five states more than states, indicating that an opportunity exists for half of children who needed mental health care did not receive it. Top states, in contrast, achieved further reductions to benchmark levels. vaccination rates of 90 percent and preventive visit • Hospital admissions and 30-day readmissions and mental health care rates that were 20 and 30 among nursing home residents increased by 8 percentage points higher, respectively. Only nine percent and 11 percent, on average, between 2000 states improved substantially (by 5% or more) on and 2006, with negative trends seen in a significant vaccination rates, while 10 lost ground. And only majority of states. Rates went up by 5 percent or 21 states improved substantially on child mental more in 29 to 37 out of 48 states for which trend health care, while 12 declined substantially. data were available for these two indicators. Rates • In 48 states, there was no appreciable change in in the worst-performing states (i.e., those with the the percentage of adults who had a usual source highest admission rates) were two to three times of care—not surprising, given the lack of improve- higher than in the best-performing states, and the ment in health insurance coverage. The proportion ranges widened. 17 • The 30-day hospital readmission rate among all • Only eight states—Connecticut, Delaware, New Medicare beneficiaries either failed to improve York, Utah, Wisconsin, Oregon, Montana, and or increased across most states from 2003–04 to Michigan—saw the equity gap narrow, with the 2006–07, with continued sharp variation across vulnerable group improving on more than half states. Readmission rates in 2006–07 ranged from of equity indicators and improving relative to the lows of 13 to 14 percent in the best-performing five national average. The greatest gains in equity across states (Oregon, Utah, South Dakota, Nebraska, and states were in mortality amenable to health care. Yet Idaho) to highs of 21 to 23 percent in the worst- even on this indicator, in only half the states was performing five states (Louisiana, Arkansas, West the gap reduced for blacks relative to the national Virginia, Nevada, and the District of Columbia). average; moreover, within all states, white–black Improvements in some states, as well as recent differences remained large. experience in some hospitals, suggest that all • In those states ranked at the top for equity overall, states could improve if incentives were better the gaps between vulnerable groups (low-income, aligned to support care transitions and improve uninsured, and minority) and national averages quality of care. tended to be smallest. Six of the 13 top-ranked • Medicare fee-for-service spending per person states—Maine, Vermont, Rhode Island, New grew by 6.5 percent per year from 2003 to 2006 Hampshire, Delaware, and Iowa—scored in the for the median state—more than twice the rate top quartile on this dimension for all three vul- of general inflation. The gap in per-beneficiary nerable groups. Conversely, five of the 13 states in spending between the highest- and lowest-cost the bottom quartile of the overall equity rankings states widened. By 2006, average per-beneficiary score in the bottom quartile for all three groups. spending in the five most costly states was 50 • In some higher-performing states, traditionally percent higher than average spending in the five disadvantaged groups reported quality of care least costly states ($9,439 vs. $6,027). that exceeded the national average. For example, • Employer premiums (including the employee the percentage of low-income diabetic patients shares) for a single individual rose an average of receiving basic recommended services was higher 4.5 percent per year in the median state from 2004 in 11 states than the national average for all diabet- to 2008; average annual increases ranged from 8.5 ics (44%). In a few instances, the care received by percent in Utah to less than 1 percent in neigh- vulnerable groups was on par with that received boring Nevada. Premiums bought less coverage, by the typically advantaged group. as annual deductibles and cost-sharing went up • The performance patterns for the equity dimension during this time. By 2008, average premiums in indicate that it is possible to close gaps—and raise the highest-cost states were 30 percent higher the floor on performance—for vulnerable groups than in the lowest-cost states ($5,056 vs. $3,904). in comparison with national averages. Equity Healthy Lives • In most states, there are wide “equity gaps” in per- • Rates of mortality for conditions amenable to formance on access and quality indicators based health care improved in most states from 2001–02 on income level, health insurance status, and race/ to 2004–05, but wide regional variation persists. ethnicity. Disturbingly, in the majority of states, Average death rates were 68.2 per 100,000 persons these equity gaps widened over time. Equity gaps in the lowest-rate states (Minnesota, Utah, were most likely to worsen for access and coordina- Vermont, Colorado, and Nebraska) compared tion of care. (Equity gaps measure the difference with 135.4 per 100,000 in states having the highest between the experiences of vulnerable population mortality rates (Mississippi, Louisiana, Arkansas, groups in each state and the national average for and Tennessee) and the District of Columbia. a total of 24 equity comparisons, only 17 of which • Looking just at white mortality rates for conditions had data that could be compared over time.) amenable to health care, the spread across states 18 is also wide, ranging from a low of 61 deaths per effectively and efficiently, so that greater value and 100,000 in Minnesota to a high of 111 deaths per greater gains in outcomes can be realized. Achieving 100,000 in West Virginia. this goal will require incentives to improve and • In all states, potentially preventable deaths among payment systems that support high-value care. There blacks are considerably higher than among whites. is also a need for greater integration of medical and Even in the five states with the lowest rates for public health interventions to help people adopt and blacks on this indicator, there is still an average maintain healthy lifestyles, as a means to counter the of 92.0 deaths per 100,000 blacks, which exceeds growing threat of obesity and prevent the develop- the national average for whites. Preventable deaths ment of chronic diseases—a major source of health among whites have gone down in most states, yet care costs. some states have had increases in black mortality, The erosion of insurance coverage (with the resulting in widening disparities. notable exception of a few states) and the high • State variations in breast and colorectal cancer uninsured rates in many states underscore the need narrowed between 2002 and 2005, as bottom- for national reform and federal action to extend af- ranked states improved faster than states with fordable insurance and ensure access for everyone. the lowest cancer mortality rates. Notably, rates Federal and national reforms also are needed to of colorectal cancer deaths in the bottom states enable all-population data, spread the adoption and are now at the median state rate observed in 2002. effective use of health information technology, and • Few states experienced appreciable improvement initiate payment reforms. The Medicare program, as in their infant mortality rates from 2002 to 2005. the single-largest payer of hospitals and physicians, Signaling the need for urgent action, several states has the ability to serve as a national leader in the area with already high rates experienced further in- of payment reform. creases, reaching an average of more than 11.0 Wide geographic variations, as well as states’ deaths per 1,000 births—more than double the commonly shared concerns over care coordination rates of states with the lowest infant mortality (4.5 and rising costs, further point to the need for national to 5.1 deaths per 1,000 births). reforms that would stimulate and support state initia- • Smoking rates among adults declined by 5 percent tives to improve performance. In the State Scorecard, or more in the majority of states from 2003–04 to those states that face the greatest health care chal- 2006–07. Yet more than one of four adults smoke lenges often have high poverty rates and more limited in high-rate states, compared with just one of 10 resources to invest in improvements. Moreover, the in Utah, the lowest-rate state. experience of the economic recession highlights the • Obesity is a growing concern across states. As challenges of “going it alone”—even for states at the of 2007, at least a quarter of children ages 10 to top of the scorecard rankings. 17 are overweight or obese in all but three states State action is similarly critical. States play many (although these states are not far behind). And roles in the health system: purchasers of coverage one of three children is overweight or obese in for vulnerable populations and for their employees; 17 states, with regional patterns closely tracking regulators of providers and insurers; advocates for mortality amenable to health care. public health; and, increasingly, conveners of and collaborators with other health system stakeholders. S u m m a ry a n d I m p l i c at i o n s State action is also key to improving primary care In the midst of the current national debate on infrastructures and community-wide systems that health system reform, the State Scorecard provides facilitate access, improve coordination, and promote a framework for states to take stock of how they are effective care. currently performing and where they have opportu- Hence, a cogent and congruent set of national and nity to improve. The challenge for all states and for state policies is needed to move the country further all private-sector health care delivery system leaders on the path to higher performance. Disparities across is this: to learn to use health care resources more states point to the importance of federal action that 19 raises the floor on performance levels across all states of primary care medical homes. The federal gov- and creates a supportive climate for state innova- ernment recently announced a new demonstration tion and achievement. The Commonwealth Fund’s that will allow Medicare to participate in such Commission on a High Performance Health System initiatives. States are also investing in key support has identified five essential strategies for compre- systems for smaller physician practices—including hensive reform. States can play an important role more nurses and modern information systems—to in fulfilling these aspirations as part of a broader facilitate delivery of effective, patient-centered care national effort. and to build community capacity. 4. Aim high to improve quality, health outcomes, 1. Affordable coverage for all. In addition to working and efficiency. Benchmarks set by leading states, toward comprehensive insurance coverage reforms, as well as exemplary models of innovation found states can improve affordable access and efficiency throughout the U.S., show that there are broad op- in the organization of insurance through effective portunities to improve and achieve better and more oversight and reform of insurance markets and affordable health care for all. Information is critical value-based purchasing of health plans for state to guide and drive change. The federal economic employees. Expanding eligibility for Medicaid stimulus legislation provides the opportunity for and CHIP and improving payment for health care states to play an important supporting role in the providers would lead to greater participation in development of health information exchanges, these programs and expand access to care for low- which can help improve quality and efficiency income families. Federal action is essential for by allowing providers to get timely information setting a national floor of coverage across states needed to treat patients effectively and prescribe that ensures access and financial protection and drugs safely. States can also play a central role eliminates disparities. in building all-population, all-payer databases 2. Align incentives with value and effective cost on costs, quality, and outcomes that can inform control. The U.S. health system’s reliance on fee- improvement and hold providers accountable for for-service reimbursement creates incentives for the care they deliver. Such systems also facilitate providers to increase the volume of services they goal-setting and monitoring of the effect of policy deliver—irrespective of the value of that care. and practice changes over time. Strategic payment reforms include reimbursing 5. Accountable leadership and collaboration to providers with more “bundled” payments for set and achieve national goals. Top-performing services with accountability to encourage effi- states set benchmarks and provide examples of the ciency, and providing financial support to develop leadership and collaboration necessary to improve. and spread primary care medical homes. Several They and other states that have made gains have states are looking to multipayer initiatives to move established quality improvement partnerships in the same direction, with an emphasis on value with other health system stakeholders to promote and on bending the cost curve. Given the frag- standard approaches to quality measurement, mentation of health insurance, it will be critical public reporting and transparency, consumer and for public and private payers to work together to provider engagement, and payment reform to en- create consistent and coherent incentives. courage value-based purchasing. With the prospect 3. Accountable, accessible, patient-centered, and of national reform, there may be new opportunities coordinated care. States can design their Medicaid for Medicare to put in place the payment policies and CHIP programs in a way that links enrollees that are necessary to move forward. with a personal source of care that can serve as a medical home to facilitate appropriate care and manage chronic conditions. Several states are col- laborating in multipayer, public–private demon- strations to develop and evaluate the effectiveness 20 The State Scorecard shows that all states can aim higher in their health system performance. But without federal reforms to help states stem rising costs and provide more affordable coverage, access will likely deteriorate. At the onset of the current recession, 1.5 million more adults were uninsured in 2008 than in 2007 because of a drop in employ- er-sponsored coverage, while the rate of uninsured children declined to its lowest level since 1987—an accomplishment made possible by coverage gains under government-provided health insurance such as Medicaid and CHIP. Estimates have the number of uninsured climbing to 61 million by 2020, with millions more expected to be underinsured. Such erosion in access and the ability to pay for care would exacerbate financial stress for families, overwhelm safety-net providers, and undermine the financial foundation of community health systems— putting quality care at risk for everyone. With rising costs putting pressure on families and businesses alike, it is urgent that states and the federal govern- ment join together to take action to enhance value in the health care system and ensure that everyone has the opportunity to participate in it fully. 21 Introduction A s states confront the shared challenges of dimensions of performance: access to care, preven- meeting their populations’ health needs tion and treatment, potentially avoidable hospital use and achieving higher-value, affordable and costs of care, equity, and the ability to live long health care systems, they need a way to take stock and healthy lives (referred to as “healthy lives”). The of their performance and identify areas for improve- analysis examines the range of variation across states ment. Benchmarks drawn from the range of states’ and assesses performance relative to what has already performance on health system measures offer one been achieved by individual states. The scorecard such way, providing achievable targets and focusing ranks all 50 states and the District of Columbia on public attention on opportunities to close the gap each of the 38 indicators and on each of the five di- with top-performing states. mensions of performance. The overall rank consists The 2009 edition of Aiming Higher: Results from a of the average across the five dimension rankings. State Scorecard on Health System Performance builds The six new indicators in the 2009 State Scorecard on The Commonwealth Fund’s series of scorecards include the following: assessing national and state health care systems across core dimensions of performance.1 The central goal of • percentage of home health patients who got better the state-level analysis is to inform action to ensure at walking or moving around; that residents of every state have access to high- • percentage of long-stay nursing home residents quality and efficient care within systems that strive who have moderate to severe pain (supplement- to improve population health. Prepared for state ing two existing nursing home quality indicators); policymakers, national leaders, and other health • hospital care intensity index (average number of care stakeholders, the State Scorecard is a resource inpatient days and inpatient physician visits among for information on states’ performance with respect chronically ill Medicare beneficiaries during the to health care access, quality, potentially avoidable last two years of life, relative to national rates); hospital use and costs, and population health. It • number of suicides (as an indicator of the adequacy also provides a means to gauge the impact of reform of mental health care); efforts and identify targets for improvement. • percentage of adults who smoke (amenable to phy- The 2009 State Scorecard has been updated and sician assessment, advice, and referral to smoking expanded from the inaugural 2007 edition. It includes cessation programs as part of broader public health 38 indicators (of which six are new), grouped into five initiatives); and • percentage of children who are overweight or Note: this report summarizes results of the State Scorecard obese (amenable to medical counseling on diet and presents overall state rankings and rankings on each and exercise as part of public health improvement). of the five dimensions of health system performance. Appendices present state-level data for all indicators, To enable assessment of change over time, we showing both current performance and changes since the expanded the baseline results from the 2007 edition baseline time period. State Scorecard Data Tables that display of the State Scorecard to include these six indicators. data and state rankings for all indicators, including data The 2009 State Scorecard ranks states relative to by income, insurance, and racial/ethnic groups for equity the performance of other states based on the most indicators, can be downloaded from the Commonwealth recent data available—typically from 2006 or 2007, Fund Web site at www.commonwealthfund.org. The Web site also provides state performance profiles that compare but with 2008 data on health coverage and insurance each state to the top state, top five states, and state median premium rates. It also assesses changes across states rates and display summary information on indicator as well as changes in each state’s performance relative rankings and time trends. An analysis of the impact on to its own baseline performance on each indicator, access, costs, and lives for each state if it were to achieve the with the periods examined ranging from two to seven top level of performance on each of 11 key indicators also can be downloaded from the Commonwealth Fund Web site. years for the 35 indicators for which there are com- parable trend data available. The analysis examines 22 ExHIBIT 6 State Ranking on Health System Performance by Dimension = State in top quartile Avoidable Prevention & Hospital Use Overall Access Treatment & Costs Equity Healthy Lives Rank* State Rank Rank Rank Rank Rank 40 Alabama 21 29 37 35 47 34 Alaska 48 40 17 23 27 36 Arizona 37 47 18 39 21 48 Arkansas 44 38 39 47 48 31 California 41 42 22 39 t 24 Colorado 40 28 15 41 1) i Connecticut e 1! 32 y e 14 Delaware 1) r 38 r 34 26 District of Columbia u 31 46 16 38 44 Florida 42 36 35 38 26 38 Georgia 36 39 24 28 37 w Hawaii y 16 t 1) w 29 Idaho 45 37 w 49 1@ 42 Illinois 20 44 49 29 32 28 Indiana 24 26 26 30 36 w Iowa r y 14 i u 23 Kansas 25 17 23 32 31 45 Kentucky 34 33 43 26 45 49 Louisiana 37 45 51 42 46 t Maine t q 18 q 23 17 Maryland 16 20 29 22 24 u Massachusetts q t 33 u y 20 Michigan 1# 15 40 14 35 r Minnesota w i 1@ 17 q 51 Mississippi 49 49 45 46 51 36 Missouri 30 30 28 33 41 18 Montana 35 25 u 20 25 1# Nebraska 25 o 1# 25 14 47 Nevada 46 51 27 48 39 t New Hampshire i w 20 r 14 30 New Jersey 27 21 48 31 19 42 New Mexico 50 50 1) 35 29 21 New York 18 22 50 1! 17 41 North Carolina 32 32 25 43 40 o North Dakota 15 14 r 1# 1) 27 Ohio 19 24 34 21 42 50 Oklahoma 47 48 44 49 44 32 Oregon 42 46 e 43 18 15 Pennsylvania 1@ 1) 31 i 33 1! Rhode Island 1! u 36 e 20 33 South Carolina 39 18 29 24 43 1@ South Dakota 17 1@ u 1@ 30 39 Tennessee 29 27 41 19 49 46 Texas 51 43 42 51 21 19 Utah 31 35 q 45 r q Vermont 1# e 1! w i 22 Virginia 22 19 21 34 28 16 Washington 23 34 y 27 1# 35 West Virginia 27 23 47 14 50 1) Wisconsin o 1# 16 18 i 25 Wyoming 32 41 o 37 16 * Final rank for overall health system performance across five dimensions SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 23 positive or negative changes in states’ performance to achieve the performance level of the top states. on the 35 indicators and assesses whether the range of Looking across dimensions, the summary section of performance across states is narrowing or widening the report discusses the primary cross-cutting findings (see Appendix A). based on state patterns and variations. These include: In cases where updated data have become available • Despite notable improvements, wide variation or measurement definitions have changed, we revised among states persists in terms of access to care, baseline data and ranks to allow “apples-to-apples” quality of care, and costs. In other words, where comparisons over time. Hence, baseline data and you live matters. ranks may differ from those initially reported in the ›› Leading states consistently outperform lagging 2007 State Scorecard. Though temporal comparisons states across indicators and dimensions. provide a useful perspective, they should be inter- ›› Across states, better access to care is closely as- preted with caution, since they represent only two sociated with better quality of care, as measured points in time. The methods box below explains the by prevention and treatment indicators. State Scorecard methodology and limitations on data ›› Public policies and public–private collabora- currently available at the state level. tion can foster an environment that supports Summary exhibits show indicators, the range of higher performance. variation across states, and overall state rankings, as • Improvements made in key areas of health care well as ranks within dimensions. Exhibit 1 shows the quality are a hopeful sign underscoring the im- overall state rankings by quartiles in the 2009 State portance of tracking performance information Scorecard and the revised 2007 State Scorecard. Exhibit and setting benchmarks to improve. 2 lists the indicators included in each dimension of • Symptoms of poor care coordination and inef- performance and illustrates the range of performance ficient or suboptimal use of resources point to across states, in both the baseline and current periods. opportunities to improve both the quality and Exhibit 3 displays trends in performance, showing costs of care. the number of states that improved, grew worse, or ›› Higher quality is not systematically associated stayed about the same for each indicator. Exhibit 6 with higher costs. shows overall state rankings and where each state ›› There are significant opportunities to reduce ranks on the five dimensions. costs while improving access and quality. The appendix to this report provides data for all • Affordability of care is a growing concern among indicators organized by dimension, including rates states. of change. The first four appendix exhibits display • All states have substantial room to improve. summary information. Exhibit A1 shows how many indicators each state had in each performance quartile. The final sections of the report examine the Exhibit A2 shows a count of indicator trends by potential impact of improving performance and dimension and Exhibit A3 shows the number of indi- implications for policy action. The analysis includes cators that improved, grew worse, or stayed about the estimates of the cumulative reductions in prevent- same for each state. Exhibit A4 summarizes changes able deaths, improvements in health care access and in the subset of equity indicators (drawn from the quality, and cost savings that would be possible if all access, prevention and treatment, and healthy lives states were to achieve the top level of performance dimensions) for each state. The appendix also includes within the current range of state variation on each demographic tables that profile states by income, of 11 key indicators. incidence of poverty, health risks, and income eligibil- The conclusion to this report outlines key areas in ity standards for public coverage programs. which state and federal action will be critical to move In the sections that follow, we present the 2009 forward. Overall, the 2009 State Scorecard shows State Scorecard results, organized by the five dimen- that we have much to gain as a nation from national sions of performance. The discussion focuses on key and state policies that aim for a higher-performing indicators and the gains possible if all states were health system. 24 W H AT T H E S C O R E C A R D M E A S U R E S Dimensions and Indicators To examine trends, we updated the baseline analysis presented in the 2007 edition to include the expanded set of measures as well The State Scorecard measures health system performance for all 50 as any refinements in methods or measures since the first release. states and the District of Columbia using 38 key indicators (Exhibit Therefore, baseline results presented in this edition are revised and 2). It organizes indicators by five broad dimensions that capture will not match results reported in the earlier report. critical aspects of health system performance: One indicator could not be updated (the percent of adult asthmatics •Access includes rates of insurance coverage for adults and with an emergency room or urgent care visit) and two indicators children and indicators of access and affordability of care. taken from the National Survey of Children’s Health are not available •Prevention and treatment includes indicators that measure on a comparable basis as a result of survey changes (the percent three related components: effective care, coordinated care, and of children with a medical and dental preventive care visit, and the patient-centered care. percent of children with a medical home). Therefore, a maximum •Potentially avoidable use of hospitals and costs of care includes of 35 indicators have data that can be compared over time. All of indicators of hospital care that might have been prevented or the updates span at least two years, with the majority spanning reduced with appropriate care and follow-up and efficient use from three to six years (one indicator shows change over seven of resources, as well as the annual costs of Medicare and private years). For some measures, data over several years were combined health insurance premiums. to enhance the sample size. Still, trends should be interpreted with •Equity includes differences in performance associated with caution since they represent only two points in time. patients’ income level, type of insurance, or race or ethnicity. •Healthy lives includes indicators that measure the degree to which See Appendix B for years, databases, and descriptions for each of a state’s residents enjoy long and healthy lives, as well as factors the indicators included in the State Scorecard. such as smoking and obesity that affect health and longevity. Scorecard Ranking Methodology Whenever possible, indicators were selected to be equivalent to those used in the National Scorecard on U.S. Health System The State Scorecard first ranks states from best to worst on each Performance. However for some areas, there are no reliable or useful of the 38 performance indicators. We averaged rankings for those measures available at the state level. For instance, databases do indicators within each of the five dimensions to determine a state’s not currently track effective management of chronic conditions, dimension rank and then averaged the dimension rankings to arrive adverse medical or medication events, or potential overuse or at an overall ranking on health system performance. This approach duplication of health services across all states. As such, the State gives each dimension equal weight and, within dimensions, Scorecard will evolve and explore these concepts as new measures weights indicators equally. We use average state rankings for the and data sources become available. State Scorecard because we believe that this approach is easily understandable. This method follows that used by Stephen In this 2009 edition, six new measures were added: two in effective Jencks and colleagues when assessing quality of care for Medicare care (home health patients getting better at walking or moving beneficiaries at the state level across multiple indicators.2 around, nursing home residents having moderate to severe pain); one in avoidable use of hospitals (Dartmouth Atlas index of hospital For the equity dimension, we ranked states based on the difference care intensity); and three in healthy lives (suicide deaths, adults between the most vulnerable subgroup (i.e., low income, uninsured, smoking, and children overweight or obese). or racial/ethnic minority) and the U.S. national average on selected indicators. The gap indicates how the vulnerable subgroup fares compared with the U.S. average—an absolute standard. 25 Access A ccess to health care is the foundation and The 2009 State Scorecard finds there are still hallmark of a high-performance health significant gaps in access to care across the nation, system. The foremost factor in determining with most states failing to improve on most of these whether people have access to care when needed is indicators. These findings are drawn from a period having health insurance that covers essential care. before the economic downturn of 2008–09, so The extent to which insurance provides affordable failure to improve and negative trends are likely access also depends on the design of benefits, and to have been a prelude to worsening access to care. whether provider payment policies secure adequate The leading states on access—concentrated in the Upper Midwest and Northeast, plus Hawaii— networks of primary and specialized care. The State tended to perform well on all four access indica- Scorecard’s access dimension looks at the percentag- tors (Exhibit 7). The top-ranked states are among es of adults and children with insurance and tracks those with the most trends in coverage. The two other indicators in this expansive policies Access: Top-Performing States dimension include the percentage of older and/or supporting public Top 5 States Rank sicker adults who are likely to need care and who health insurance for Massachusetts 1 visited a doctor in the last two years for a routine low- and moderate- Minnesota 2 checkup (including adults ages 50 and older, in fair income families and Connecticut 3 or poor health, or with selected chronic conditions) insurance market Iowa 4 and the percentage of adults who reported that they reforms to expand Maine 5 went without care because of costs. coverage (see table). ACCESS EXHIBIT 7 State Ranking on Access Dimension WA ME MT ND VT MN NH OR NY MA ID SD WI CT MI RI WY NJ PA IA NE MD DE OH NV IN UT IL WV DC CO VA CA KS MO KY NC TN AZ OK SC NM AR GA MS AL LA TX FL AK State Rank Top Quartile HI Second Quartile Third Quartile Bottom Quartile SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 26 Massachusetts garnered the top ranking because with the number of uninsured Americans projected it has the lowest rate of uninsured residents in to grow from 46 million currently to at least 61 the country—an especially notable achievement million by 2020.3 In most states, rates of health given that the scorecard data reflect a period during insurance coverage for adults ages 18–64 failed implementation of recent reforms in that state. to improve or deteriorated between 2004–05 and 2007–08, the periods examined in the two editions pa r t i c i pat i o n of the State Scorecard. Absent federal reform, health care coverage and As of 2007–08, one of five nonelderly adults was access are expected to deteriorate in coming years, uninsured, on average, across the nation—even before A C C E S S : P A R T I C I P AT I O N EXHIBIT 8 Percent of Adults Ages 18–64 Uninsured by State 1999–2000 2007–2008 WA ME WA ME MT ND VT MT ND VT MN NH MN NH OR NY MA OR NY MA ID SD WI CT ID SD WI CT MI RI MI RI WY NJ WY NJ PA PA IA IA NE MD DE NE MD DE OH OH NV IN NV IN UT IL WV DC UT IL WV DC CO VA CO VA CA KS MO KY CA KS MO KY NC NC TN TN AZ OK SC AZ OK SC NM AR NM AR GA GA MS AL MS AL LA LA TX TX FL FL AK AK HI HI Less than 14% 14%–18.9% 19%–22.9% 23% or more DATA: U.S. Census Bureau, 2000–01 and 2008–09 Current Population Survey ASEC Supplement SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 A C C E S S : P A R T I C I P AT I O N EXHIBIT 9 Percent of Children Ages 0–17 Uninsured by State 1999–2000 2007–2008 WA ME WA ME MT ND VT MT ND VT MN NH MN NH OR NY MA OR NY MA ID SD WI CT ID SD WI CT MI RI MI RI WY NJ WY NJ PA PA IA IA NE MD DE NE MD DE OH OH NV IN NV IN UT IL WV DC UT IL WV DC CO VA CO VA CA KS MO KY CA KS MO KY NC NC TN TN AZ OK SC AZ OK SC NM AR NM AR GA GA MS AL MS AL LA LA TX TX FL FL AK AK HI HI Less than 7% 7%–9.9% 10%–15.9% 16% or more DATA: U.S. Census Bureau, 2000–01 and 2008–09 Current Population Survey ASEC Supplement SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 27 A C C E S S : P A R T I C I P AT I O N EXHIBIT 10 Percent of Adults and Children Uninsured by State, 2007–08 Adults ages 18–64 uninsured Children under age 18 uninsured 40 30 Adults Uninsured = 20.0% U. S. Average 20 10 Children Uninsured = 10.4% U. S. Average 0 ts ps a Co H h i r e e c aii es M icut Al r gin e ab ia ich a ic t W ndiaan o f i s co na lu sin M Illin ia ne is N o Ar O h a Pe ash mona nn ing t r t h k an io N e a ko s De Yo a M l aw a k od yla e e I nd d iss ia Ke a k o r i W tuc a Te om k y es g Ka see O k Ida as lah ho br a N o Ca U a r t h li fo t ah r a o a M rego a Lo nt a n N e uis na C Jer a M o l o r s ey Fl o a d a iss o h C la i ar sk a N e Ari lina M na N e x i co Te da s lva n ut A ipp D sa xa m I ow i n M am ni Ca rni G e olin R h ar r Ne om O rgi w ian W Ver sot w t n t k r iss ad nn in V i lan s y to h D ou in o So M rgin b et ns as n n aw t V ai I ig w zo ri Co n m v o t us e s o ch y Ha sa ut as w W So M Ne st r Di Data: U.S. Census Bureau, 2008–09 Current Population Survey ASEC Supplement SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 the onset of the economic recession. Across states, the points—reversing earlier gains. The gap between the percentage of nonelderly adults who were uninsured best and worst states in terms of children’s coverage ranged from a low of 7 percent in Massachusetts and remains wide, ranging from a low of 3 percent 11 percent in Hawaii and Minnesota to a high of 30 uninsured children in Massachusetts to a high of 20 percent in New Mexico and Texas. percent in Texas (Exhibit 10). Since the beginning of the decade, there has been In all, 38 states experienced some decline in the considerable erosion in coverage for adults. Between percentage of children or adults with insurance. 1999–2000 and 2007–08, the number of states with Therefore, moving coverage trends in more positive high rates of uninsured adults under age 65 (23% directions is a broad concern. or more) rose from just two to nine (Exhibit 8). These trends do not yet capture the full effects In contrast, the number of states with low rates of of the 2008–09 recession, such as the loss of em- uninsured adults (under 14%) declined from 22 to ployer-sponsored insurance attributable to job 11 (including the District of Columbia). losses. The reauthorization and expansion of the Between 1999–2000 and 2007–08, uninsured rates Children’s Health Insurance Program (CHIP) in among adults and children moved in different direc- 2009 could make up to 4 million more children tions, as a result of federal/state action to improve eligible for CHIP coverage over the next four years coverage for low- and moderate-income children if states match federal funding,4 which would help to (but not for adults). The number of states with high offset the effects of the recession (e.g., loss of family rates of uninsured children (16% or more) declined health coverage) on rates of children’s coverage. Yet from nine to three (Exhibit 9). Alabama is particularly states are facing deficits even with federal stimulus notable among southern states for having among the support—making it difficult to hold the line on lowest rates of uninsured children. coverage. In California, for example, the number Still, from 2004–05 to 2007–08, the uninsured of uninsured children may double in the coming rate among children failed to improve in close to half months as state budget cuts, and the consequent of states. In four states, the percentage of uninsured loss of federal matching dollars, are expected to cut children actually increased by at least three percentage CHIP funding nearly in half.5 28 P hys i c i a n V i s i t s a n d Co s t B a r r i e r s visits and not forgoing care because of costs). Many of the states that improved the most or ranked high, Not surprisingly, given these insurance trends, the such as Massachusetts and West Virginia, achieved share of at-risk adults (those who are age 50 or above, their progress by closing gaps between high- and chronically ill, or rated their health as fair/poor) who low-income individuals with respect to insurance visited a doctor for a routine checkup in a two-year coverage or other access indicators. period either failed to improve substantially or Notably, gains in coverage for adults did not declined across states from 1999–2000 to 2006–07 always translate to improvement on other access (Appendix Exhibit A6). The percentage of at-risk indicators (i.e., routine checkups and not forgoing adults who had not seen a doctor for two years for care because of costs). This indicates that it may take a checkup ranged from a low of 7 percent in Rhode time for coverage expansions to reduce cost or other Island to 25 percent in Oklahoma, the lowest-ranked barriers to care noticeably. The most recent research state. Compared with the 2007 State Scorecard, the on the Massachusetts health insurance reforms spread across states widened. bears this out: as of the fall of 2008, two years after Similarly, there was no improvement in the insurance reforms were implemented, barriers to care number of adults saying they went without care have been reduced and affordability has improved.6 because of costs. Responses ranged from a low of 7 Across all of the access indicators, the picture percent in Hawaii, Massachusetts, and North Dakota generally remained more positive in the Upper to a high of 19 percent in Mississippi and Texas. Midwest and Northeast and worse in western and S o m e Stat e s southern states. Some states in the South (West D e m o n s t r at e I m p r o v e m e n t Virginia, Alabama, and Georgia) and West (Utah, Montana, California, and Wyoming) improved In spite of the lack of improvement overall, several their ranking relative to other states because they states stand out as high performers in providing access performed better than average. Rates of coverage for to care or having made substantial gains, compared adults and children increased in West Virginia, while with their baseline scorecard rates. Between 2004–05 coverage rates declined for both groups in neighbor- and 2007–08, Massachusetts—which had just begun ing Virginia and Kentucky. The ranking of a number to implement its universal coverage program—saw of southern states declined because of worse perfor- the greatest increase in coverage rates for adults and mance on the two measures gauging barriers to care. further increased its already-high child coverage rates. In contrast, some states that improved their ranking, It is now the top-ranked state in providing coverage such as Georgia and Wyoming, did so primarily by for both adults and children. Like Massachusetts, holding the line while other states declined. other states that are in the top five performers in the access dimension—Minnesota, Connecticut, and T h e N e e d f o r F e d e r a l Act i o n Maine—have supported major coverage expansions. Some states have achieved comparatively low Maine is notable in this respect, since its median uninsured rates for children, despite having high adult income is well below that of the other leading states. uninsured rates (Exhibit 10). Federal support provides But improvement was not limited to states that states with resources to expand Medicaid or CHIP historically have been active in expanding access to programs by raising eligibility thresholds or offering care. West Virginia moved from the bottom to the 12-month continuous eligibility. These strategies have top of the third quartile of states in this dimension, helped states such as West Virginia and Arkansas hold with adult and children coverage rates improving by down uninsured rates for children, despite having 2.3 percentage points each from 2004–05 to 2007–08 adult uninsured rates at or above the national average. period. Although West Virginia still ranked low on Large differences between the eligibility standards measures of care utilization, it was one of the few for public health insurance programs for children and states that held steady or experienced marginal those for adults contribute to the uneven progress improvement in adults’ reports of access (i.e., checkup made in covering both groups. Nearly all states extend 29 ACCESS EXHIBIT 11 State Ranking on Access and Prevention/Treatment Dimensions Top Rank 1 VT DE NH ME MA IA 6 RI MN NE PA State Ranking on Prevention and Treatment CT 11 SD WI ND MI HI 16 KS SC VA MD NJ 21 NY WV MT OH IN 26 TN CO AL MO DC 31 NC KY WA UT FL 36 ID AR GA AK R2 = 0.71 WY 41 CA TX IL LA OR 46 OK AZ MS NM NV 51 Bottom 51 46 41 36 31 26 21 16 11 6 1 Rank Top State Ranking on Access Rank SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 CHIP coverage to children in families with incomes efforts by states. At the same time, state policies and up to 200 percent of the federal poverty level (FPL) or strategies, including simplification of the enrollment higher—as much as 350 percent of FPL.7 Meanwhile, process for public insurance and outreach to ensure few states cover adults at this income level. In 34 states, that all who qualify participate, can make a differ- families would have to have incomes below 100 percent ence. States also can enhance access to care in low- of the poverty level in order for parents to qualify for income, rural, and other underserved communities by Medicaid; in 14 of these states, income thresholds for investing in primary care, community health centers, parents are set below 50 percent of poverty. Thirty and other safety-net resources. states do not cover childless adults at any income level Acc e s s P r o m ot e s Q ua l i t y unless they are disabled (Appendix Exhibit A7).8 With the exception of a few states, insurance Across states, better access to care and higher rates coverage is eroding across the nation—and espe- of insurance are closely associated with better quality cially across the South and West—underscoring the of care, as measured by prevention and treatment challenge to state-based coverage expansion initia- indicators (Exhibit 11). In states where more people tives. State fiscal constraints, which may be exacerbat- are insured, adults and children are more likely than ed once federal stimulus funding expires, combined those in states with lower insurance rates to have with the erosion of job-based coverage, indicate that a usual source of care or a primary care “medical achieving significant coverage expansions will require home” (a regular source of care that meets criteria federal action. for effective and patient-centered care coordina- To raise the floor on state performance and ensure tion; see Appendix B for complete definition) and access to care for everyone, federal policies are to receive recommended preventive and chronic necessary to galvanize and sustain public expansion care. Eleven of the 13 states in the top quartile of 30 the access dimension also rank in the top quartile coverage and better care point to a pressing need of states on the prevention and treatment quality for national action to expand insurance coverage dimension (discussed below). Moreover, states with and ensure access to care. low prevention and treatment quality rankings tend to have high uninsured rates—a relationship that Prevention and Treatment P occurs at the community level as well.9 atients and families seeking health care Identifying delivery system practices as well rightly expect that their physician will as state policies that promote access to care and a recommend effective and needed services culture of quality is essential to improving health (without prescribing unnecessary care), that their care outcomes and lowering costs. The number of care will be well coordinated among different care uninsured children declined following enactment providers, and that those who deliver their care of federal Medicaid expansions and creation of the will be responsive to their needs. Despite the best efforts of caregivers, fragmentation in the health Children’s Health Insurance Program (CHIP), and care system too often makes it hard to meet these the number should decline further with the recent expectations. Moreover, the increasing complexity CHIP expansion—assuming states are able to fulfill of medicine means that care providers need tools their roles in matching federal funding. Yet the high and strategies to practice effectively. States can play and rising rates of uninsured adults put states and an important role in promoting higher-quality care the nation at risk as adults lose affordable access through policy, leadership, and collaboration— to care and financial security. The deterioration such as by convening all stakeholders to find ways in coverage and the relationship between better to improve. P R E V E N T I O N & T R E AT M E N T EXHIBIT 12 State Ranking on Prevention and Treatment Dimension WA ME MT ND VT MN NH OR NY MA ID SD WI CT MI RI WY NJ PA IA NE MD DE OH NV IN UT IL WV DC CO VA CA KS MO KY NC TN AZ OK SC NM AR GA MS AL LA TX FL AK State Rank Top Quartile HI Second Quartile Third Quartile Bottom Quartile SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 31 The good news: there has been substantial im- Prevention & Treatment: provement on prevention and treatment quality Top-Performing and Most-Improved States indicators over the periods reported in the 2007 and Count of indicators that improved 2009 editions of the State Scorecard—more than in Top 5 States Rank by 5% or more* any of the other dimensions of performance. The Maine 1 8 bad news: wide gaps and variations persist—both New Hampshire 2 9 within and across states—in the provision of effective, Vermont 3 9 coordinated, and patient-centered care. Nine of the 14 Delaware 4 10 prevention and treatment indicators for which there Massachusetts 5 8 are comparable data in both the baseline and current States with Count of indicators Most Improved that improved periods improved substantially (by 5% or more) in Indicators Rank by 5% or more* the median state and in the majority of states; state Utah 35 12 variation substantially narrowed for seven of these Arkansas 38 12 nine. There was little or no change in four quality West Virginia 23 11 indicators and two could not be compared across Ohio 24 11 these periods (Exhibits 2 and 3 and Appendix Exhibits * Count is out of total of 14 indicators with trends (13 for MA). A2 and A9). Even when quality indicators did not improve on Hospitals and nursing homes—both of which average, some states registered substantial gains in are the focus of national performance reporting performance. Such progress suggests that improve- and improvement initiatives—achieved the largest ment is within reach of all states. gains in this dimension. In contrast, ambulatory Eff e ct i v e C a r e care quality barely changed (2% on average across five comparable indicators). Ambulatory Care. As with other dimensions of the State Scorecard, Across the nation, there are major shortfalls in the there continue to be wide performance variations delivery of recommended preventive care to adults across states, with distinct geographic patterns on and in the delivery of basic services to help prevent overall rankings on quality (Exhibit 12). With some complications for those with diabetes (Exhibit 13). exceptions, the top-ranked states tend to be located in Almost two-thirds of adults age 50 and older in the New England and the Upper Midwest, while bottom- lowest-ranked states did not report timely receipt of ranked states are located in the South, Southwest, and recommended cancer screenings and vaccinations. West. Overall, bottom-performing states would need to Even in the top-ranked states just half of such adults improve their indicator rates by 40 percent on average received all recommended cancer screenings and to reach the level achieved by top-performing states. immunizations. Preventive care rates range from a The five top-performing states on prevention and high of 53 percent in Delaware to a low of 35 percent treatment quality—Maine, New Hampshire, Vermont, in Oklahoma. On this indicator, half of states saw Delaware, and Massachusetts—generally performed little change and half improved by 5 percent or more. better than other states across indicators of effective The rate of delivery of diabetic services in the and coordinated care. The leading states did not consis- best-performing state (Minnesota, at 67%) was double tently perform better on indicators of patient-centered that in the worst state (Mississippi, at 33%). Perfor- care or long-term care, however (Appendix Exhibit mance on this indicator declined or failed to improve A8). Several states demonstrated impressive gains in substantially in 24 of 42 states for which there were quality of care relative to their peers. In four states, available trend data. California increased the rate of more than three-quarters of the indicators improved delivery of diabetic services by 12 percentage points, by 5 percent or more (see table).Utah, which was one moving from the fourth to the first quartile. Correla- of two states with the most indicators that improved by tion across state rates on these two indicators of the 5 percent or more, moved up in rank from the fourth quality of ambulatory care suggests that there may to the third quartile of states on this dimension. be common pathways to improvement. 32 P R E V E N T I O N & T R E AT M E N T : E F F E C T I V E C A R E EXHIBIT 13 State Variation: Ambulatory Care Quality Indicators Percent Best state Top 5 states average All states median Bottom 5 states average Worst state 100 93 90 85 80 83 73 71 67 67 62 60 57 53 51 50 45 42 36 35 35 33 0 Adults age 50+ received Adult diabetics received Children ages 19–35 months Children with medical and recommended preventive care three recommended received five vaccines dental preventive care visits diabetes services Top 5 states 1. Delaware 1. Minnesota 1. New Hampshire 1. Rhode Island 2. Connecticut 2. Vermont 2. Maryland 2. Massachusetts 3. Minnesota 3. Maine 3. Connecticut 3. Connecticut 4. Rhode Island 4. Wisconsin 4. Hawaii 4. District of Columbia 5. Michigan 5. North Dakota 5. South Dakota 5. New Hampshire 5. Maryland DATA: Adult preventive care—2006 BRFSS; Adult diabetic preventive care—2006–07 BRFSS; Child vaccines—2007 National Immunization Survey; Child medical and dental visits—2007 National Survey of Children’s Health SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 More than one-quarter of young children in the Hospital Care Clinical Quality Indicators. worst-performing five states did not receive preventive Performance on indicators of the quality of care medical and dental visits and key vaccinations, and provided in hospitals is a bright spot in the State in the bottom five states more than half who needed Scorecard, with substantial improvement from 2004 to mental health care did not receive it, based on parents’ 2007 across 48 states on an expanding set of evidence- reports. The best-performing states, in contrast, based treatment standards for heart attack, heart achieved vaccination rates of 90 percent. Indicators failure, and pneumonia (Exhibit 14.) The median state gauging receipt of children’s preventive and mental rate reached 92 percent on a composite measure of health care were 20 and 30 percentage points higher, care for these three conditions. In 2007, the worst-per- respectively, in top states than in bottom states. Most forming states reached performance levels achieved states did not make progress in these areas, with only by the top-performing states three years earlier, and nine improving substantially on vaccination rates and the entire distribution shifted upward. Among the 21 making progress in delivering mental health care. three conditions, however, state variation remains Nevertheless, some states demonstrated impres- three times wider for heart failure and much wider sive gains. New Hampshire, Maryland, and Hawaii for pneumonia than for heart attack care—indicat- improved vaccination rates by 8 to 10 percentage ing there is substantial room for improvement in points, moving from the third and fourth quartiles providing basic care for people hospitalized with to the top five states. Rates of receipt of mental health these conditions (Appendix Exhibit A10). care grew by 10 to 20 percentage points in the most- An expanding set of measures gauging the delivery improved states. of recommended care to prevent surgical complications 33 P R E V E N T I O N & T R E AT M E N T : E F F E C T I V E C A R E EXHIBIT 14 State Variation: Hospital Care Quality Indicators, 2007 Percent of patients who received recommended care* Best state Top 5 states average All states median Bottom 5 states average Worst state 100 98 98 96 95 95 95 94 92 93 91 92 91 90 88 86 86 85 82 76 71 50 0 All three conditions Heart attack Heart failure Pneumonia (19 indicators) (8 indicators) (4 indicators) (7 indicators) Top 5 states 1. New Hampshire 1. Vermont 1. New Jersey 1. Vermont 1. North Dakota 1. New Hampshire 2. New Hampshire 2. New Hampshire 3. Nebraska 3. South Dakota 2. North Dakota 3. New Jersey 4. Iowa 3. Nebraska 4. Delaware 3. Maine 5. South Dakota 5. Iowa 5. Maine 5. Iowa * See Appendix B for description of clinical indicators. DATA: 2007 CMS Hospital Compare SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 P R E V E N T I O N & T R E AT M E N T : E F F E C T I V E C A R E EXHIBIT 15 State Variation: Prevention of Surgical Complications Percent of adult surgical patients who received appropriate care to prevent complications* 100 2004 2007 93 91 90 83 85 80 78 71 58 51 50 0 Best state Top 5 states average All states median Bottom 5 states average Worst state * Data for 2004 is a composite of two clinical indicators; 2007 is a composite of five clinical indicators consisting of original two in 2004 and three new indicators. See Appendix B for description of clinical indicators. DATA: 2004 and 2007 CMS Hospital Compare SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 34 improved by 8 percentage points in the top five states and rates of insurance coverage, since having insurance is by 22 percentage points in the bottom five states, cutting the most important predictor of having a usual source the variation between the five best and five worst states of care.10 On average, only three of five children had in half (Exhibit 15). Although in 2007 a sizeable spread a primary care medical home. Rates varied from less between the top- and bottom-ranked states persisted, the than half of children having a medical home in the lowest-ranked states had achieved performance levels bottom states to about two-thirds in the top-ranked above the median rate three years earlier. states (Exhibit 16). These positive trends in hospital quality likely As with other publicly reported hospital quality reflect the influence of national consensus on a indicators, rates of provision of written discharge single set of measures, public reporting of results of instructions to heart failure patients—a basic require- these measures on the federal government’s Hospital ment for helping them make the transition from Compare Web site, and widespread hospital par- the hospital to their home or another care setting— ticipation in data reporting following its linkage to improved substantially. The median rate across states Medicare payment updates. increased by almost 50 percent, the largest improve- ment on any State Scorecard indicator (Exhibit 17). Co o r d i n at e d C a r e All states improved substantially, such that the rate In contrast, there was no change in 48 states in the achieved in the lowest state by 2007 exceeded the proportion of adults reporting they have a usual care median rate in 2004. Despite improvement on this provider, with a 20-percentage-point difference in indicator, hospital readmission rates continue to be rates persisting between top and bottom states. This a concern, as discussed below. More robust measures is not surprising, given the stagnation and decline in of care transitions, together with effective care P R E V E N T I O N & T R E AT M E N T : C O O R D I N AT E D C A R E EXHIBIT 16 State Variation: Coordination of Care Indicators Percent Best state Top 5 states average All states median Bottom 5 states average Worst state 100 91 89 89 87 82 75 71 69 69 68 61 62 54 49 50 45 0 Adults with a usual source of care Children with a medical home Heart failure patients given discharge instructions Top 5 states 1. Pennsylvania 1. New Hampshire 1. South Dakota 1. Delaware 2. Nebraska 2. North Dakota 3. Maine 3. Vermont 3. New Hampshire 4. Massachusetts 4. Iowa 4. Idaho 5. New Hampshire 5. Massachusetts 5. Delaware 5. Ohio DATA: Adult usual source of care—2006–07 BRFSS; Child medical home—2007 National Survey of Children’s Health; Heart failure discharge instructions—2007 CMS Hospital Compare SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 35 P R E V E N T I O N & T R E AT M E N T : C O O R D I N AT E D C A R E EXHIBIT 17 State Variation: Hospital Discharge Planning Percent of heart failure patients discharged home with written instructions 100 2004 2007 91 87 84 75 70 62 54 51 50 26 14 0 Best state Top 5 states average All states median Bottom 5 states average Worst state DATA: 2004 and 2007 CMS Hospital Compare SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 management interventions, will be needed to avoid whether these shifts represent an enduring change adverse events and return trips to the emergency in patients’ experiences. department or hospital. Long-Term and Home Health Care. Pat i e n t - C e n t e r e d C a r e, Three measures of patient-centered nursing home I n c lu d i n g C a r e f o r F r a i l care (percentage of high-risk nursing home residents E l d e r ly a n d D i s a b l e d with pressure sores; percentage of residents who were physically restrained; and percentage of residents with Compared with variation seen on other quality moderate to severe pain) showed marked improve- indicators, state-by-state variation was narrow on ment from 2004 to 2007, with gains of 13 to 36 percent two measures of patient-centered care received by in median state rates and a 30 percent narrowing in Medicare beneficiaries: the percentage who say their the range of performance across states. In 38 states, providers always listen, explain, show them respect, pressure sore rates fell substantially (by 5% or more); and spend enough time with them and the percentage across all states, rates of use of physical restraints and who give a best rating for the health care they received pain reports also fell substantially (Appendix Exhibit during the past year (Exhibit 2). In 2003 (the year of A9). Despite these gains, variation remains wide, with the data reported in the previous State Scorecard), twofold to fivefold variation from the top five to the beneficiaries’ ratings of their interactions with care bottom five states on these three measures. providers and their overall care experiences tended Nursing home quality and the public reporting to be similar across the nation. By 2007, ratings on of quality data for benchmarking and comparative these indicators consistently diverged across all states, purposes have been the focus of federal and state with beneficiaries giving higher ratings to provider initiatives, augmented by collaborative efforts to interactions and lower ratings to their overall care improve. Recently, a national “Advancing Excel- experiences. lence in America’s Nursing Homes” campaign has These results, however, should be interpreted with targeted improvements on the indicators included in caution, owing to changes in survey administration the State Scorecard. Nursing homes that participate in 2007.11 Longer time trends and data from other in the campaign do better than those that choose patient demographic groups will be needed to judge not to participate, and participating homes that set 36 specific targets for improvement do better than those essential to inform improvement efforts and provide that merely pledge to improve.12 incentives to improve. The expansion of publicly Performance on an indicator of home health care available all-payer, population-based data, including outcomes—the percentage of patients who expe- information on clinical outcomes drawn from elec- rienced improvement in mobility—improved sub- tronic medical records, has the potential to support stantially across 43 states and by 12 percent in the state and private efforts to improve—particularly to median state (Appendix Exhibit A9). The range of achieve better health outcomes. state variation widened, however, as top states pulled ahead. State-level performance on this indicator Potentially Avoidable Use does not correlate closely with other indicators in of Hospitals and Costs of Care I the quality dimension, with some top-ranked states nefficient or wasteful health care and high and performing poorly and four bottom-ranked states rising health care costs are the leading impedi- performing in the top quartile. This may reflect the ments to ensuring accessible, high-quality care. relatively unique nature of home health care services, The State Scorecard focuses on important indica- which have likely benefitted from a national improve- tors of efficient care: rates of potentially avoidable ment campaign. and expensive hospital care. A more comprehen- Sp r e a d i n g t h e G a i n s sive assessment of health system efficiency would compare indicators of inappropriate care, waste, In summary, there remains much room for improve- and administrative overhead, but such measures ment among states, with even top-ranked states per- are not available at the state level. forming poorly on some indicators of health care The State Scorecard also includes two indicators quality. Strategies being followed by leading states of health care costs: 1) the average cost of single include creating incentives to raise the quality of care, private health insurance premiums paid by convening leadership groups, and collaborating with employers and workers and 2) annual spending private and public sector payers to promote a more per Medicare beneficiary. Higher costs are not responsive and effective health care delivery system. necessarily indicators of inefficiency if there is a For example, states such as Pennsylvania and Rhode return on investment for extra spending in terms of Island are collaborating in multipayer, public–private more accessible care or better quality and outcomes. demonstrations to develop and evaluate the effective- Yet we include these cost indicators in this ness of primary care medical homes, which hold dimension, because studies of health care spending promise for delivering better-coordinated, patient- and health care systems within the United States centered care. as well as international comparisons document Encouraging the adoption of systemic improve- multiple instances of inefficient, duplicative, ments will require national cooperation and sustained wasteful, or potentially excessive care and find that federal and state support for infrastructure, such higher spending is not systemically related with as electronic health records. The federal stimulus better outcomes.13 legislation provides the opportunity for states to play Overall trends in this dimension were unfavor- an important supporting role in the development able. Performance on five of the nine indicators for of health information exchanges, which can help which trend data are available worsened by 5 percent improve quality and efficiency as providers get timely or more, and variation among states more often information they need to treat patients effectively and widened than narrowed (one indicator could not prescribe drugs safely. Likewise, the Children’s Health be updated). A twofold to threefold spread persisted Insurance Program Reauthorization Act ushered in between top and bottom states on key indicators. new federal support for quality improvement and Notably, health care costs continued their long- reformed payment policies. running upward trend, with growing burdens on Information systems for benchmarking and families as coverage has become less affordable and comparing quality and monitoring change are changes to health benefit designs have shifted more 37 costs to patients and their families.14 The 2009 State hospital to nursing home and back, worsened signifi- Scorecard finds that health care costs are rising faster cantly in the majority of states since the beginning of than incomes. There is continued wide variation the decade (Appendix Exhibit A12). across states in rates of potentially preventable use Each of the five top-ranked states on this of hospitals and emergency departments—pointing dimension—Utah, Idaho, Oregon, North Dakota, to underlying patterns that drive up the costs of care and Hawaii—has relatively low rates of potentially and undermine affordability. avoidable hospital use, including readmissions, and Geographic patterns of avoidable utilization and relatively lower premiums and Medicare costs per costs have changed little since the 2007 State Scorecard, beneficiary. Notably, despite already having low rates with better performance (i.e., lower admission rates of potentially avoidable hospital use in the 2007 State and costs) concentrated in the West and Upper Scorecard, several of the leading states improved their Midwest (Exhibit 18). Poor performance (i.e., higher performance on these indicators. costs and higher rates of potentially preventable Nevertheless, reflecting the overall unfavorable hospitalizations) remains concentrated in the South performance in this dimension, no state exhibited and Northeast. Rates of 30-day hospital readmissions substantial improvement on more than half the in- among Medicare beneficiaries for selected conditions dicators (see table). South Dakota improved on the increased by 5 percent or more in 16 states. Thirty states most indicators by 5 percent or more, including a failed to improve on this indicator from 2003–04 to substantial reduction in hospital readmissions— 2006–07. Rates of hospital admissions among nursing resulting in the state’s move from near the bottom home patients, as well as rates of 30-day cycling from on this dimension to near the top. AV O I D A B L E H O S P I TA L U S E & C O S T S EXHIBIT 18 State Ranking on Potentially Avoidable Use of Hospitals and Costs of Care Dimension WA ME MT ND VT MN NH OR NY MA ID SD WI CT MI RI WY NJ PA IA NE MD DE OH NV IN UT IL WV DC CO VA CA KS MO KY NC TN AZ OK SC NM AR GA MS AL LA TX FL AK State Rank Top Quartile HI Second Quartile Third Quartile Bottom Quartile SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 38 Avoidable Hospital Use & Costs: asthma and 2) ambulatory care sensitive (ACS) condi- Top-Performing and Most-Improved States tions among Medicare beneficiaries. On both indica- Count of indicators tors, the majority of states had lower rates of admis- that improved Top 5 States Rank by 5% or more* sions than in the previous State Scorecard (Exhibit 3). Utah 1 2 Hospital Admissions for ACS Conditions. Idaho 2 1 By 2006–07, hospital admissions for one of 11 ACS Oregon 3 2 conditions among Medicare beneficiaries were North Dakota 4 2 lower than in 2003–04 in all but a few states, based Hawaii 5 1 on a sample of Medicare claims data. In 36 states, States with Count of indicators Most Improved that improved such rates declined by at least 5 percent (Exhibit Indicators Rank by 5% or more* 19). Several southern states that had among the South Dakota 7 4 highest ACS admission rates in 2003–04 showed Minnesota 12 3 improvements. The rates in Mississippi, Oklahoma, Colorado 15 3 Georgia, Tennessee, and Kentucky dropped sig- Arizona 18 3 nificantly. While the range of variation among states Rhode Island 36 3 narrowed somewhat, rates of potentially preventable Kentucky 43 3 admissions were 2.5 times higher in the highest-rate West Virginia 47 3 state than in the lowest-rate state (9,331 vs. 3,725 per Louisiana 51 3 * Count is out of total of 9 indicators with trends 100,000 beneficiaries). This indicates that there (8 for ID, LA, ND, and SD; 7 for HI). is broad opportunity for further improvement, particularly for efforts to avoid complications of Potentially Avoidable Use of Hospitals chronic conditions among elderly adults living in Across states, most indicators of potentially avoidable the community. An essential first step is to ensure use of hospitals worsened or failed to improve from that all patients have a relationship with a primary the baseline to current Scorecard periods, with two care provider who is accessible and can effectively notable exceptions: 1) admission rates for pediatric coordinate their care. AV O I D A B L E H O S P I TA L U S E & C O S T S EXHIBIT 19 State Rates of Hospital Admissions for Ambulatory Care Sensitive Conditions Among Medicare Beneficiaries Admissions per 100,000 beneficiaries 12,000 2006–07 2003–04 2006–07 All States Median = 6,291 10,000 8,000 6,000 4,000 2,000 0 th D lina Ore tah Wis orida Vir sin ia w H Ma a am ine Ma hire Mo land rth ntana G ota Sou nec ia No Caro ut Sou Caro a Ka ta Pen ichig as nsy an Ind ia a tric Okla souri Ma Colum a chu bia Ne etts ers k ey Ten linois see Ala hio a s Ken sippi ode ucky st V sland Lou ginia na Ha n Wy waii shi ing on Ari ho Min zona Ne ta Ala a Col ska V ado w M nt Cal xico De rnia Ne ware Fl ka Mis as Mis ansa Iow lin ian hom bam vad Ne w Yor go gin Con eorg n ako o Ne ermo tic M ns Tex s isia ngt Ida con lva O om k nes U nes bra or s ps ifo e ry Da t la sis ir wJ I Il Ark ssa th rth Wa We t of Rh No Ne Dis DATA: 2003–04 and 2006–07 Medicare SAF 5% Data SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 39 Hospitalization rates among children with severity of conditions, changes in practice patterns asthma declined in most of the 32 states that (such as outpatient treatment of community-acquired collected and reported this information over the pneumonia), or better care management. The imple- two periods; the rates in three-fourths of these states mentation of Medicare prescription drug coverage in declined by at least 5 percent. Lack of data on the January 2006 may have contributed to reduced hos- number of children with asthma, and on hospital- pitalizations by helping beneficiaries adhere to drug ization rates among children with asthma in the regimens that prevent disease complications. Further other states, makes it difficult to assess progress investigation is warranted to determine underlying on this indicator. It is encouraging that states with causes for trends in specific conditions.15 the highest asthma admission rates in 2003 were Hospital Readmission Rates Among Medicare among the most improved—somewhat narrowing Beneficiaries and Hospital Use Among the variation across states. Still, a threefold spread Nursing Home and Home Health Residents. in hospitalization rates persists from top to bottom. Rates of hospital readmission within 30 days among The five states with the highest admission rates Medicare beneficiaries and hospital use among improved nearly 14 percent between 2003 and 2005, nursing home and home health residents vary widely while the five states with the lowest rates improved across states (Exhibit 20). Across most states, rates about half that much. on both indicators either increased or failed to Readers should exercise caution in interpreting improve (Exhibit 3). geographic data on avoidable use of hospitals, as The negative trends observed among nursing rates can be higher or lower due to any of a number home residents are of particular concern, since of factors, including the underlying prevalence or moving in and out of hospitals puts frail elders at AV O I D A B L E H O S P I TA L U S E & C O S T S EXHIBIT 20 State Variation: Hospital Admissions Indicators Percent Best state Top 5 states average All states median Bottom 5 states average Worst state 50 43 40 31 28 29 27 25 25 22 23 22 21 21 19 18 14 15 13 13 9 7 0 Medicare beneficiaries readmitted Nursing home residents Nursing home residents readmitted Home health patients to hospital within 30 days admitted to hospital to hospital within 30 days admitted to hospital Top 5 states 1. Oregon 1. Minnesota 1. Utah 1. Utah 2. Utah 2. Arizona 2. Vermont 2. Washington 3. South Dakota 3. Oregon 3. Idaho 3. North Dakota 4. Nebraska 4. Utah 4. South Dakota 3. Oregon 5. Idaho 5. Colorado 5. Montana 5. South Dakota DATA: Medicare readmissions—2006–07 Medicare 5% SAF Data; Nursing home admission and readmissions—2006 Medicare enrollment records and MEDPAR file; Home health admissions—2007 Outcome and Assessment Information Set SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 40 risk of complications.16 Rates of hospital readmission Hospital Care Intensity. within 30 days of discharge to a nursing home A new State Scorecard indicator finds threefold increased by 5 percent or more from 2000 to 2006 variation among states in the propensity to use in 37 of the 48 states for which trends are available. hospital services intensively to care for chronically Disturbingly, the rate grew by 15 percent or more in ill Medicare beneficiaries during their last two years 13 geographically disparate states (Appendix Exhibit of life (Exhibit 21). The Dartmouth Atlas Hospital A12). Similarly, hospital admission rates among Care Intensity (HCI) index measures the amount long-stay nursing home residents rose in the vast of time such Medicare beneficiaries spent in the majority of states (39 of 48), increasing by 5 percent hospital, and the number of physician visits they or more in about two-thirds of the states (29 of 48). received while hospitalized. It is expressed as a ratio Rates in the highest-rate states were two to three times of each state’s average to the national average (see higher than in the lowest-rate states, and the ranges box for methodology). between states widened. Methodology: Hospital Care Intensity (HCI) Index Among all Medicare beneficiaries who were hos- The HCI index is based on two variables: the number of days pitalized during 2006–07, nearly one of five (18.4%) patients spent in the hospital and the number of physician returned to the hospital within 30 days. Medicare encounters (visits) they experienced as inpatients during their last two years of life. The population includes Medicare readmission rates increased by 5 percent or more beneficiaries with one or more of nine chronic illnesses who in 16 states and declined by this amount in only five died during the particular year.19 The HCI index is computed states, with a failure to improve nationally from the as the age-sex-race-illness standardized ratio of patient average rate (18.0%) in 2003–04. Readmission rates days and visits. For each variable, the index calculates the in 2006–07 ranged from lows of 13 to 14 percent ratio of a given state’s use rate to the national average and then averages the two ratios to create the overall index. in the best-performing five states (Oregon, Utah, The national average was set to 1.0 for the base year 2001, South Dakota, Nebraska, and Idaho) to highs of 21 so that ratios in subsequent years reflect the national to 23 percent in the worst-performing five states trend in this composite measure of inpatient utilization.20 (Louisiana, Arkansas, West Virginia, Nevada, and the District of Columbia). Notably, the readmission States with the highest HCI index scores (New Jersey, New York, Louisiana, Nevada, and Florida) rate declined in Oregon—already the lowest-rate state make much greater use of the hospital than states with in 2003–04—suggesting that there is significant room the lowest scores (Utah, Idaho, Oregon, Washington, to improve across the nation. and Wyoming). Moreover, several of the states with Hospital readmissions are receiving national the largest populations (New York, Florida, Califor- attention as a symptom of fragmentation and lack nia, Illinois, Pennsylvania, and Texas) dominate the of coordination in the health care delivery system. group, with HCI scores greater than the national The nearly twofold spread among states on rates of average. In New Jersey (the state with the highest 30-day readmissions among Medicare patients points score in 2005), chronically ill Medicare beneficiaries to the need to reform provider incentives, strengthen spent over 25 days in the hospital and received over primary care, and manage care during transitions 61 inpatient physician visits on average during their between care settings. last two years of life. In contrast, such patients in Performance on another indicator of potentially Utah (the state with the lowest score in 2005) were avoidable hospital use—hospital admissions among hospitalized for 11 days and received 15 physician home health care patients—declined or failed to visits at the end of life. improve between 2004 and 2007 in the majority of The Dartmouth researchers who developed the states. Admission rates were up by 5 percent or more index found that regions and states with higher HCI in 27 of 51 states; rates improved (i.e., decreased) scores had lower hospital clinical quality scores and by 5 percent or more in only five states (Appendix lower patient ratings of hospital care—suggest- Exhibit A12). ing poorer coordination of care.17 They also have 41 AVOIDABLE HOSPITAL USE & COSTS EXHIBIT 21 documented that areas of the country with greater hospital intensity have higher mortality rates (after State Variation: Hospital Care Intensity Index, 2005 adjusting for differences in patients’ illnesses and Higher than the New Jersey severity of disease).18 Hence, states and regions National Average where there is more conservative use of hospitals to 1.5 manage chronically ill patients at the end of life—the regions that also tend to place greater emphasis on primary care—likely deliver better value for health care spending than those with greater intensity of hospital care for these patients. As with other State Scorecard indicators of po- tentially avoidable hospital use, performance on the New York HCI index failed to improve in most states and in the nation overall. With 2001 as the base year (1.0), 1.25 District of Columbia the average national HCI rate remained about the same in 2003 and 2005, although it worsened by Louisiana about 2 percent between 2001 and 2005. Seven states Nevada Florida (Arkansas, Delaware, Hawaii, Mississippi, New California Illinois Pennsylvania Mexico, Rhode Island, and South Dakota) improved Texas their standing on the HCI between 2003 and 2005 by Delaware at least 5 percent, while three states (Ohio, Montana, Mississippi and Vermont) saw a worsening in their HCI score by Hawaii Michigan at least that amount. United States Tennessee South Carolina 1.0 Kentucky Arkansas Co s t s o f C a r e Maryland West Virginia Missouri Alabama Connecticut Ohio All states experienced substantial increases in the Oklahoma Massachusetts Virginia costs of care since the first State Scorecard (from 2003 Georgia Rhode Island to 2006). At the same time, substantial variation in Arizona Kansas per-person spending persisted across the states. Some Indiana drivers of health spending, such as underlying wage North Carolina Nebraska differentials, are beyond the reach of health policy reform. But other factors are amenable to public policies and private initiatives. Such factors include Iowa 0.75 South Dakota Colorado the degree to which primary care is supported and the New Hampshire Wisconsin Maine degree to which financial incentives encourage high- Alaska Minnesota quality, efficient care, including well-coordinated Vermont care for those with chronic illness. Policies across Montana New Mexico North Dakota the country designed to reform payment methods, Wyoming advance patient-centered medical homes, and spread Washington the adoption and effective use of health information technology hold considerable promise, but they have Lower than the Oregon National Average Idaho not yet produced a discernable impact on cost trends 0.5 Utah across the states. As spending has increased, variation in spending Note: The Hospital Care Intensity Index was calculated as the average of the across the states has widened. Yet research has consis- number of inpatient days by state divided by the national rate and the number of inpatient physician visits by state divided by the national rate, for chronically tently shown that higher spending is not associated illness standardized. The national average was set to 1.0 for the base year 2001, with better outcomes or better patient experiences, measure of inpatient utilization. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 42 aV o i d a B l e h o s P i Ta l u s e & C o s T s ExHIBIT 22 Median Income, Health Insurance Premiums as Percent of Income, and Percent of Nonelderly Adults Uninsured by State Employer premiums as percent Median household income of median household income Percent of nonelderly adults for under-65 population for under-65 population (ages 18–64) uninsured 2007 2008 2007–08 2003–04 2007 Rank 2003 2008 Rank 2004–05 2007–08 Rank United States $48,442 $53,685 15.0 17.2 19.6 20.0 Alabama 46,000 48,000 41 14.9 17.5 32 19.1 17.0 25 Alaska 56,108 65,850 6 15.5 16.2 19 22.3 24.1 45 Arizona 42,500 49,600 39 16.3 18.9 42 23.2 23.6 43 Arkansas 37,899 49,090 40 17.3 18.8 41 23.9 24.0 44 California 46,030 52,000 32 14.8 17.1 27 23.7 24.4 47 Colorado 53,430 64,830 7 13.8 13.9 2 19.3 19.7 31 Connecticut 65,032 69,150 4 12.6 14.3 5 14.5 13.3 8 Delaware 52,000 60,000 13 15.4 16.7 23 15.6 14.3 12 District of Columbia 40,000 42,904 51 16.9 19.0 43 16.3 12.0 5 Florida 45,000 50,000 35 16.2 18.5 37 26.2 25.9 48 Georgia 45,000 54,202 29 14.9 16.1 16 22.7 22.8 42 Hawaii 48,084 53,680 30 12.1 14.1 4 11.9 10.6 2 Idaho 47,322 56,834 20 15.5 16.1 16 19.0 20.1 33 Illinois 52,016 57,000 18 14.7 16.9 25 17.0 17.8 26 Indiana 50,000 56,611 21 15.0 18.1 34 17.7 16.6 22 Iowa 53,650 58,050 17 13.1 14.8 7 11.6 12.8 6 Kansas 51,082 55,000 27 14.5 16.0 15 14.3 16.1 19 Kentucky 42,419 46,000 45 16.8 19.5 47 17.7 19.9 32 Louisiana 38,700 45,000 48 17.8 18.7 40 24.2 26.2 49 Maine 45,840 55,045 25 17.7 19.0 43 12.7 13.3 8 Maryland 60,000 69,500 3 11.8 13.3 1 17.4 16.8 24 Massachusetts 60,432 63,867 8 12.4 15.6 11 13.9 7.2 1 Michigan 52,490 60,000 13 14.7 15.3 9 14.8 16.1 19 Minnesota 63,510 68,000 5 12.9 15.4 10 10.4 10.8 3 Mississippi 39,018 43,094 50 16.8 20.0 49 22.0 24.2 46 Missouri 50,967 50,000 35 14.1 17.3 28 15.8 16.6 22 Montana 37,457 50,000 35 17.8 17.4 30 21.7 21.1 36 Nebraska 52,082 57,000 18 14.4 16.5 20 14.4 15.8 18 Nevada 45,000 52,000 32 15.0 16.9 25 21.9 21.6 39 New Hampshire 66,078 74,317 1 12.3 14.9 8 13.2 13.9 11 New Jersey 65,000 69,560 2 12.2 13.9 2 18.1 18.8 30 New Mexico 36,300 45,000 48 19.7 19.0 43 25.3 30.2 50 New York 47,000 51,101 34 15.1 17.6 33 17.3 18.0 28 North Carolina 43,662 46,002 44 15.6 19.9 48 19.7 21.1 36 North Dakota 49,750 56,250 23 13.3 15.9 14 13.4 14.3 12 Ohio 51,084 55,025 26 14.5 16.1 16 14.3 15.5 16 Oklahoma 42,162 48,000 41 17.1 18.3 36 24.9 22.0 41 Oregon 45,350 52,305 31 15.1 18.1 34 21.2 21.6 39 Pennsylvania 52,178 56,500 22 13.8 16.5 20 13.3 12.9 7 Rhode Island 52,031 58,800 16 14.2 16.8 24 14.2 14.4 14 South Carolina 44,488 50,000 35 16.2 18.6 39 22.0 20.6 35 South Dakota 49,818 54,922 28 14.6 15.8 13 15.3 15.1 15 Tennessee 44,064 46,000 45 17.4 20.3 50 17.7 20.1 33 Texas 40,050 45,640 47 18.4 19.3 46 29.6 31.5 51 Utah 52,033 60,090 12 14.0 16.5 20 18.4 16.2 21 Vermont 52,606 55,506 24 14.1 18.5 37 15.0 13.5 10 Virginia 56,000 61,000 11 12.9 14.7 6 17.2 17.9 27 Washington 54,400 62,300 10 13.7 15.7 12 17.1 15.7 17 West Virginia 38,400 46,066 43 19.3 23.1 51 23.4 21.1 36 Wisconsin 52,760 62,485 9 14.8 17.3 28 13.1 11.9 4 Wyoming 51,560 59,136 15 16.0 17.4 30 17.6 18.2 29 DATA: Median household incomes—2004–05 and 2008 Current Population Survey ASEC Supplement; Average premiums for employer-based health insurance plans (weighted by single and family household distribution)—2003 and 2008 Medical Expenditure Panel Survey; Uninsured—2005–06 and 2008–09 Current Population Survey ASEC Supplement SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 43 making the continuing increases and wide range of Over a longer five-year period, affordabil- spending especially troubling.21 ity of health insurance has declined as premiums Total Medicare fee-for-service spending per ben- have risen faster than wages or other measures eficiary for hospital (Part A) and physician (Part B) of patients’ ability to pay.23 By 2008, the average benefits provides a good basis for contrasting state employer insurance premiums (including employer spending, since such benefits are uniform across the and employee shares) relative to income amounted states. Per-beneficiary spending grew by 6.5 percent to 16 percent or more of state median household per year from 2003 to 2006 for the median state— income for the under-65 population in 37 states, more than two times the increase in the Consumer up from 16 states in 2003 (Exhibits 5 and 22). In Price Index, which grew at an average annual rate of 18 states, premiums relative to annual incomes 3.1 percent for this period. During this time, Medicare amounted to 18 percent or more of median incomes costs grew more than twice as fast in Iowa and New for the under-65 population. In only three states Hampshire (almost 9% per year) than in New Jersey, (Colorado, New Jersey, and Maryland), average Hawaii, and Delaware (under 4% per year). The differ- premiums were less than 14 percent of median ence in costs per beneficiary between the highest- and income. The increasing cost of health insurance lowest-cost states widened by nearly 10 percent. As puts moderate- and middle-income families at risk a result, by 2006, average per-beneficiary spending of joining the ranks of the uninsured. Millions of in the five most costly states was nearly $3,500 more workers and their families were in a precarious than average spending in the five lowest-cost states position going into the 2008–09 recession. ($9,439 vs. $6,027). The 50 percent variation in per- Opp o r t u n i t i e s to R e d u c e beneficiary spending suggests that there are oppor- Av o i d a b l e U s e a n d Co s t s tunities for reducing unnecessary use of services and The close link between high rates of potentially for engaging patients and physicians alike in making avoidable hospital care and Medicare spending informed treatment choices. suggests opportunities to reduce cost while improving Private-sector health care costs also rose in care. As illustrated in Exhibit 4, states with high recent years and vary across the states. The average readmission rates also have the highest per capita employer-sponsored health insurance premium Medicare spending. This association has drawn the for single coverage (i.e., employer and employee attention of federal and state policymakers as well as shares combined) increased more than 4.5 percent private insurers. There is broad interest in creating per year from 2004 to 2008 in close to half of the incentives to improve the organization and delivery of states. Premium growth is likely to understate the care, including methods that would bundle payments total impact of rising health costs, because even as for episodes of care (e.g., creating a single payment premiums have risen, patient cost-sharing or limits for hospital stays, readmissions, and post-acute care) on benefits have increased.22 and pay-for-performance initiatives.24 States also are All states saw insurance premium increases from examining strategies to strengthen primary care, 2004 to 2008, with an average annual increase of 6 promote care coordination through health informa- percent or more in New Hampshire, West Virginia, tion technology, and enlist nurses to provide better and Utah. In contrast, premiums rose by half that care during transitions. rate—less than 3 percent per year on average—in six The five top-ranked states on the dimension— states (Michigan, Oklahoma, Texas, Virginia, Ohio, Utah, Idaho, Oregon, North Dakota, and Hawaii— and Nevada). The average premium increased by 8.5 generally performed better across indicators of poten- percent per year in Utah as compared with less than tially avoidable hospital use as well as those measuring 1 percent per year in neighboring Nevada during this costs of care (for which data were available). Utah, period. In 2008, average premiums in the highest-cost home to highly integrated systems of care, stands out states were nearly one-third (30%) higher than in the as an example of better performance across both cost lowest-cost states ($5,056 vs. $3,904). and use indicators. 44 Equity A state’s health system should be judged by On most of the equity comparisons (15 of all 17 how well it performs for its most vulner- with trend data), vulnerable groups were more likely able residents. Through programs such to fare worse both in relation to the national average as Medicaid and the Children’s Health Insurance and in absolute terms over time (Exhibit 23). The Program (CHIP), all states devote considerable greatest gains were in rates of mortality amenable resources to providing care for low-income residents to health care. Yet even on this indicator, blacks and other vulnerable groups. Policy strategies such as reduced the gap relative to the national average in raising eligibility thresholds for public coverage and only half the states, and the gap worsened in seven eliminating barriers to enrollment and retention can others. Moreover, differences between whites and contribute substantially to improved access to care blacks within each state remained wide (see discus- for such groups. By building on efforts to promote sion under “Healthy Lives,” below). At the same health system capacity and quality of care overall— time, equity gaps widened in 27 to as many as 41 with an explicit focus on safety-net providers serving states on interrelated indicators of access and coor- primarily low-income and uninsured patients—states dination of care. Typically, the increase in the gap can reduce disparities in health care access and quality. reflected worse access and care experiences for the The State Scorecard assesses equity by comparing vulnerable group. gaps in performance among subgroups of patients by States ranked at the top of the equity dimension income level, insurance coverage, and race/ethnicity. tend to have the smallest gaps in performance The analysis compares performance levels among between national averages and low-income, each state’s most vulnerable populations to a common uninsured, and minority groups (Exhibit 24). Six of benchmark—the national average—for a subset of the 13 top-ranked states—Maine, Vermont, Rhode indicators.25 We call the difference between the state’s Island, New Hampshire, Delaware, and Iowa— most vulnerable group and the national average the score in the top quartile on this dimension for all “equity gap.” three population groups (income level, insurance Featured indicators draw from each of the di- coverage, and race/ethnicity). Conversely, five of mensions where data are available by the relevant the 13 states in the bottom quartile of the overall subgroups. In total, there are 24 equity comparisons: equity ranking score in the bottom quartile for all nine by income, six by insurance coverage, and nine three groups. by race/ethnicity (Exhibit 23). Only 17 of these had States that rank high on the equity dimension are data that could be compared over time. located in the Upper Midwest and the Northeast. To assess progress over time, we count how often The lowest-ranked states are in the South and West. the equity gap narrowed across the available indica- But as seen in the first State Scorecard, other states in tors for each state in the periods between the 2007 these regions—including West Virginia, Alaska, and and 2009 editions of the State Scorecard. We consider Montana—rank in the top half of the equity rating improvement to have occurred only when perfor- overall and in the top quartile of one subgroup. This mance for the most vulnerable group also improved, pattern suggests that states facing similar regional since a narrowing in the equity gap resulting only circumstances and challenges can still effectively from a decline in the national average does not make tackle disparities in care. the vulnerable group better off.26 Despite progress in some states, there are wide Only eight states—Connecticut, Delaware, New equity gaps in State Scorecard measures for vul- York, Utah, Wisconsin, Oregon, Montana, and nerable populations, with the extent of dispari- Michigan—saw at least half of their equity indica- ties varying across the states. States that perform tors improve, such that the gap narrowed and per- well among all populations on overall statewide formance levels among the most vulnerable group rankings—and on access and quality in particular— improved (Appendix Exhibit A4). tend to have smaller equity gaps among vulnerable 45 eQuiTy ExHIBIT 23 Summary of Changes in Equity Dimension Number Gap Narrowed Gap Widened of States Gap and Low-Income Gap and Low-Income Change in U.S. with Data Narrowed Group Improved Widened Group Worsened Average Rate Income 1 Percent uninsured, ages 0–64 50 22 22 27 27 Worsened 2 Percent of at-risk adults have not visited a doctor for routine checkup in the past two years 51 16 8 35 35 Worsened 3 Percent of adults with a time in the past year when they needed to see a doctor 51 13 13 35 35 Worsened but could not because of cost 4 Percent of adults age 50 and older did not receive recommended 51 15 15 35 21 Improved screening and preventive care 5 Percent of adult diabetics did not receive recommended preventive care 42 13 13 28 21 Improved 6 Percent of children without both a medical and dental preventive care visit in the past yeara — — — — — — 7 Percent of adults without a usual source of care 51 17 17 34 29 Improved 8 Percent of children without a medical homea — — — — — — 9 Percent of adult asthmatics with an emergency room or urgent care visit in the past yearb — — — — — — Number Gap Narrowed Gap Widened of States Gap and Uninsured Gap and Uninsured Change in U.S. with Data Narrowed Group Improved Widened Group Worsened Average Rate Insurance Coverage 1 Percent of at-risk adults have not visited a doctor 51 10 4 41 41 Worsened for routine checkup in the past two years 2 Percent of adults with a time in the past year when they needed to see a doctor 51 23 22 27 27 Worsened but could not because of cost 3 Percent of adults age 50 and older did not receive recommended 51 19 19 31 23 Improved screening and preventive care 4 Percent of children without both a medical and — — — — — — dental preventive care visit in the past yeara 5 Percent of adults without a usual source of care 51 18 18 33 33 Improved 6 Percent of children without a medical homea — — — — — — Number Gap Narrowed Gap Widened of States Gap and Non-White Gap and Non-White Change in U.S. with Data Narrowed Group Improved Widened Group Worsened Average Rate Race/Ethnicity 1 Percent uninsured, ages 0–64 43 21 19 22 22 Worsened 2 Percent of at-risk adults have not visited a doctor 49 14 11 35 35 Worsened for routine checkup in the past two years 3 Percent of adults with a time in the past year when they needed to see a doctor 51 21 20 28 28 Worsened but could not because of cost 4 Percent of adults age 50 and older did not receive recommended 47 21 21 26 19 Improved screening and preventive care 5 Percent of children without both a medical and — — — — — — dental preventive care visit in the past yeara 6 Percent of adults without a usual source of care 51 22 22 29 28 Improved 7 Percent of children without a medical homea — — — — — — 8 Mortality amenable to health care, 43 24 24 19 7 Improved deaths per 100,000 population 9 Infant mortality, deaths per 1,000 live births 47 25 25 21 21 Same a Data are not comparable over the two time periods because of changes in survey design. b Data could not be updated. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 46 EQUITY EXHIBIT 24 Equity Dimension and Equity Type Ranking State Rank Top Quartile Second Quartile y y Third Quartile uit uit Eq Eq y y Bottom Quartile uit uit ge ge Eq Eq e ra e ra ty ty it y it y ov ov ici ici 2009 Ranking Revised 2007 Ranking* qu qu eC eC t hn t hn eE eE nc nc /E /E u ra u ra om om ce ce Inc Inc Ins Ins Ra Ra RANK S TAT E RANK S TAT E 1 Maine 1 Massachusetts 2 Vermont 2 Maine 3 Rhode Island 2 Vermont 4 New Hampshire 4 New Hampshire 4 Delaware 4 Rhode Island 6 Connecticut 6 Hawaii 7 Massachusetts 6 Connecticut 8 Iowa 6 Pennsylvania 8 Pennsylvania 9 Delaware 10 Hawaii 10 District of Columbia 11 New York 11 Ohio 12 South Dakota 11 Maryland 13 North Dakota 13 South Dakota 13 Wisconsin 14 Michigan 14 West Virginia 15 Iowa 16 District of Columbia 16 North Dakota 17 Minnesota 17 New York 18 Wisconsin 18 Kentucky 19 Tennessee 19 West Virginia 20 Montana 20 New Jersey 21 Ohio 21 Michigan 22 Maryland 22 Alaska 23 Alaska 23 Nebraska 24 South Carolina 24 Missouri 25 Nebraska 25 Montana 26 Kentucky 25 Illinois 27 Washington 27 Minnesota 28 Georgia 27 Kansas 29 Illinois 29 Wyoming 30 Indiana 30 Virginia 31 New Jersey 30 Tennessee 32 Kansas 30 South Carolina 33 Missouri 33 Washington 34 Virginia 33 North Carolina 35 New Mexico 35 Louisiana 35 Alabama 36 Alabama 37 Wyoming 37 Indiana 38 Florida 38 Utah 38 Georgia 39 California 39 Arizona 40 Colorado 41 Colorado 40 Florida 42 Louisiana 42 Arizona 43 Oregon 43 New Mexico 43 North Carolina 44 California 45 Utah 45 Idaho 46 Mississippi 46 Arkansas 47 Arkansas 47 Mississippi 48 Nevada 48 Oregon 49 Idaho 48 Oklahoma 49 Oklahoma 50 Texas 51 Texas 50 Nevada * Some state rates from the 2007 edition have been revised to match methodology used in the 2009 edition. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 47 populations. This relationship indicates that states systems support their residents’ ability to live long that do better for their populations overall also tend and healthy lives and further explores disparities by to do better for their most vulnerable groups on race or ethnicity on selected mortality indicators. indicators examined by the State Scorecard (most I n co m e a n d I n s u r a n c e of the equity indicators are drawn from the access and prevention and treatment dimensions). In most states, access to and quality of care varies Some higher-performing states provide care to by income and insurance, with lower income and traditionally disadvantaged groups at rates that are lack of insurance associated with poorer access and better than the national average on some indicators. lower quality. Gaps are widest in states that perform For example, the percentage of low-income diabetic poorly on indicators of quality and access overall. patients receiving basic recommended services was Across all equity indicators, states in which low-in- higher in 11 states (e.g., 63% in Minnesota) than the come and uninsured individuals lost ground outnum- national average for all diabetic patients across the bered states in which these groups advanced in relation nation (44%). In a few instances, care for the most to the national average over the periods assessed by vulnerable group was on par with that provided to the the State Scorecard. For most of these indicators, the typically advantaged group. States with large equity equity gaps widened in both top- and bottom-ranked gaps might learn lessons from the care management strategies in these better-performing states. states on equity. Widening equity gaps were especially Conversely, in states that rank low on overall striking on indicators of access and coordination of performance across all five dimensions, low perfor- care: in 35 states, low-income adults were increas- mance extends even to high-income, insured, and ingly less likely to visit a physician over the periods non-minority groups. assessed by the State Scorecard, and in 29 states they The following section examines gaps in terms of were less likely to have a usual source of care (Exhibit access to and quality of care, focusing on disparities 23). Likewise, in 41 states uninsured adults were less by income level and insurance status. The “Healthy likely to have physician visits, and in 33 states they were Lives” section, below, examines how well state health less likely to have a usual source of care. EQUITY EXHIBIT 25 Lack of Recommended Preventive Care by Income and Insurance Percent of adults age 50+ who did not receive recommended preventive care 100 By income 100 By insurance More than 200% of poverty 200% of poverty or less Insured Uninsured 84 Overall U.S. average = 58 75 76 70 64 60 59 55 56 51 51 50 44 50 0 0 National Top 5 states Bottom 5 states National Top 5 states Bottom 5 states average average average average average average Note: Top 5 states refer to states with smallest gaps between overall U.S. average and low-income/uninsured groups. Bottom 5 states refer to states with largest gaps between overall U.S. average and low-income/uninsured groups. DATA: 2006 BRFSS SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 48 EQUITY EXHIBIT 26 Children Without a Medical Home by Income and Insurance Percent of children without a medical home 100 By income 100 By insurance 400% of poverty or more Less than 100% of poverty Private insurance Uninsured 75 71 Overall U.S. average = 43 64 61 50 45 50 45 36 32 34 31 29 28 0 0 National Top 5 states Bottom 5 states National Top 5 states Bottom 5 states average average average average average average Note: Top 5 states refer to states with smallest gaps between overall U.S. average and low-income/uninsured groups. Bottom 5 states refer to states with largest gaps between overall U.S. average and low-income/uninsured groups. DATA: 2007 National Survey of Children’s Health SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 Income and insurance equity gaps are particularly bottom-ranked states, with close to a twofold spread wide in terms of receipt of preventive care (Exhibit in the equity gap (Exhibit 26). 25). On average, across the nation 76 percent of In most states, performance variation on many uninsured and 70 percent of low-income adults age indicators is much greater among uninsured than 50 and older did not receive all recommended cancer among insured populations. For instance: screening and immunizations, compared with 56 • The proportion of uninsured adults who reported percent of insured and 51 percent of higher-income not seeing a doctor because of costs ranged from adults. A similar pattern exists for diabetes care. On 30 percent in the five states with the narrowest average, 61 percent of low-income diabetic patients equity gap to 52 percent in the five states with the did not receive basic care according to guidelines for widest gap on this indicator. This was four times their condition (although this represents an improve- the state variation among those with insurance, ment from 67% in 2003–04). which ranged from 5 percent to 11 percent between Part of whether children have a medical home the top-five and bottom-five states. depends on their family’s income and their insurance • Across the nation, on average only 13 percent of status. Top-ranked states on equity were more likely adults with insurance coverage reported not having than other states to provide children with medical a usual source of care—an important determinant homes overall, including those in low-income families of whether people receive preventive care. Among or without health insurance. Even though vulner- the uninsured, proportions without a usual source able children in the top-ranked states were less likely of care ranged from 42 percent in the states with than their higher-income or insured counterparts the smallest equity gap to 67 percent in the states to have medical homes, performance rates for the with the largest gap. vulnerable groups were at the national average. In Race and Ethnicity: Access and Quality contrast, medical home rates among children in low-income families or without health insurance The State Scorecard also compares access to and were much lower than the national average in the quality of care by racial and ethnic groups, focusing 49 on states that have substantial minority populations of lacking a primary care medical home to coordi- and sufficient data for analysis. Because minorities nate their care: medical home rates among minority often have lower incomes and are more likely to children were 19 to 30 percentage points lower than be uninsured than whites, the disparities observed among white children. Minority adults, too, are at among minorities also reflect differences related to greater risk than whites of missing recommended income and insurance status. preventive care. Equity gaps by race or ethnicity were more likely to Some states ranked low on measures of equitable widen than narrow as a result of worsening performance care for racial/ethnic minorities as a result of severe among the most vulnerable nonwhite group across four shortfalls for selected minority groups that comprise of seven indicators for which trend data were available relatively small shares of these states’ total popula- (Exhibit 23). Most states made progress on the other tions. For example, Minnesota’s scores were often three indicators: rates of mortality amenable to health low for a racial/ethnic category that included Asian care, infant mortality rates, and rates of older adults Americans and Native Americans. For these states, receiving recommended preventive care. Still, large improvement efforts focused on these population equity gaps remain on these indicators. groups could substantially reduce health disparities.27 Minorities fare substantially worse than whites on Some states stand out in terms of achieving most indicators in most states, though their experi- more equitable treatment of minorities. Reflect- ences vary across states. Hispanics have the highest ing the influence of state coverage policy, the uninsured rate in nearly all states—on average, almost uninsured rate among blacks is almost equal to three times that of whites (Exhibit 27). In states with that of whites in Tennessee and approaches the the widest equity gaps, nearly half of all nonelderly national rate for whites in Wisconsin, Massachu- Hispanics are uninsured. Hispanics also are the setts, and the District of Columbia. Likewise, the most likely to report not having a regular source of uninsured rate among Hispanics is almost half the care among racial/ethnic population groups (40% national average for Hispanics in Pennsylvania of Hispanics vs. 16% for whites). Black, Hispanic, and near the national average for whites in Mas- and other minority children are all at higher risk sachusetts and Hawaii. EQUITY EXHIBIT 27 Prevention/Treatment and Access Indicators by Race/Ethnicity, National Averages Percent White Black Hispanic Other 100 72 62 63 62 55 56 51 50 35 32 21 18 12 0 Adults age 50+ did not receive Children without a medical home Nonelderly adults recommended preventive care (under age 65) uninsured DATA: Adult preventive care—2006 BRFSS; Child medical home—2007 National Survey of Children’s Health; Uninsured—2007–08 Current Population Survey ASEC Supplement (data represents 2006–07) SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 50 In eight states (Delaware, Maryland, Michigan, care and treatment across all states. Where people Missouri, Montana, Ohio, Pennsylvania, and live, how much they earn, and what their racial or Wisconsin), black or Hispanic adults are more likely ethnic background is should not determine the kind than whites nationally—and at least as likely as whites of health care they receive. in their own state—to receive all recommended cancer screenings and immunizations. Minority children Healthy Lives H also do relatively better than white children across elping adults and children lead healthy states in terms of receipt of preventive medical and lives and avoid sickness and disability is dental visits, with black children more likely to receive an overarching goal of health care systems preventive visits in two-thirds of the states for which and a challenge for state medical care and public data are available. This likely reflects the influence of health systems. Millions of Americans suffer from expanding coverage to low-income children through chronic disease, and the number with such con- Medicaid and CHIP as well as requirements for the ditions is expected to continue to climb rapidly. delivery of preventive care under Medicaid’s Early Heart disease, cancer, and diabetes account for the and Periodic Screening, Diagnostic, and Treatment majority of premature deaths in the United States. (EPSDT) program. The future burden of such diseases will be fueled Altogether, the State Scorecard paints a sobering by the epidemic of obesity, unless trends abate. picture of equity gaps that remain large and in many States are looking for comprehensive approaches cases appear to be widening. Federal policy action is that emphasize prevention and better management clearly needed to support more equitable access to of these conditions, as well as public health initiatives H E A LT H Y L I V E S EXHIBIT 28 State Ranking on Healthy Lives Dimension WA ME MT ND VT MN NH OR NY MA ID SD WI CT MI RI WY NJ PA IA NE MD DE OH NV IN UT IL WV DC CO VA CA KS MO KY NC TN AZ OK SC NM AR GA MS AL LA TX FL AK State Rank Top Quartile HI Second Quartile Third Quartile Bottom Quartile SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 51 that address population risk factors. These include Healthy Lives: policies and programs intended to stem the rise of Top-Performing and Most-Improving States obesity, curb smoking, and promote healthy lifestyles, Count of indicators that improved by while ensuring the delivery of preventive services and Top 5 States Rank 5% or more* effective care for chronic conditions. Minnesota 1 4 The State Scorecard gauges how well states Hawaii 2 4 strengthen opportunities for achieving optimal health Connecticut 3 6 and quality of life for their residents. There is little Utah 4 3 question that health outcomes are heavily shaped California 5 5 by forces both outside and inside the health care Count of indicators system. Income, education, and housing and work States with Most that improved by Improved Indicators Rank 5% or more* environments significantly influence the extent to Connecticut 3 6 which people are able to live healthy and produc- Oregon 18 6 tive lives. Other health determinants that are closely New Jersey 19 6 intertwined with cultural and socioeconomic factors Georgia 37 6 also affect people’s expectations of and interactions District of Columbia 38 6 with the health system. By assessing mortality rates * Count is out of a total of 8 indicators. and other health outcomes, the State Scorecard does not aim to dismiss the complex nature of state-level deaths were restricted even further to younger differences in health, but rather it seeks to highlight age ranges). The United States fell into last place important targets for system improvement. among 19 industrialized countries between 1997–98 The 2009 State Scorecard analysis found con- and 2002–03. While the overall rate of mortality tinuing large variation in health outcomes across amenable to health care went down in the U.S., the states on multiple indicators. Regional patterns pace of improvement in the other countries over remained relatively constant, with top-ranked states the same period was greater.28 spread across parts of the Upper Midwest, West Updated state-level analyses prepared for the State (including the Mountain and Pacific regions), and Scorecard find that the median state rate of deaths New England (Exhibit 28). Minnesota—the top- from conditions amenable to health care declined by 6 ranked state on this dimension—was the only state percent from 2001–02 to 2004–05 (95.6 to 89.9 deaths to consistently perform in the top quartile on all indicators of healthy lives. Wisconsin moved into per 100,000) (Exhibit 29). In a handful of states, the the top quartile of states—reaching the top quartile rates of preventable deaths decreased by 15 percent or of performance on three indicators and becoming more. Minnesota and Vermont—which had among one of the most improved states on two indicators: the lowest rates in the country in the beginning of rates of mortality amenable to health care and rates the decade—further lowered their death rates, setting of nonelderly adults with activity limitations. In five new benchmarks. The lowest state rates now near states, three-quarters of the indicators improved by results achieved in the best country (65 deaths per 5 percent or more (see table). 100,000 in France). For the most part, rates of deaths from conditions amenable to health care improved P ot e n t i a l ly P r e v e n ta b l e M o r ta l i t y across all states, except for Arkansas, Nevada, and Mortality amenable to health care represents the Louisiana, which saw minimal or no change. best measure available to summarize state varia- Still, wide regional variation remains. There is a tions in health outcomes. This age-standardized twofold range across the top- and bottom-five states. measure includes deaths before age 75 caused by at In the best-performing states (Minnesota, Utah, least partially preventable or treatable conditions, Vermont, Colorado, and Nebraska), rates are half those such as bacterial infections, certain screenable in the District of Columbia and lagging states (Missis- cancers, diabetes, heart disease, stroke, asthma, sippi, Louisiana, Arkansas, and Tennessee). Average and surgical complications (for some conditions, death rates were 68.2 per 100,000 persons in the top 52 H E A LT H Y L I V E S EXHIBIT 29 Mortality Amenable to Health Care by State Deaths* per 100,000 Population 2004–05 2001–02 2004–05 WA ME 160 151 MT ND VT NH 144 142 OR MN NY MA 135 ID SD WI CT MI RI WY PA NJ 120 IA NE MD DE OH NV IL IN 96 UT CO WV VA DC 90 KS CA MO KY 78 NC 80 72 68 OK TN 64 AZ AR SC NM GA MS AL TX LA 40 FL AK Quartile (range) HI 0 Top (63.9–76.8) Best: MN Best state Top 5 All Bottom 5 Worst Second (77.2–89.9) states states states state** average median average Third (90.7–107.5) Bottom (108.0–158.3) Worst: DC * Age-standardized deaths before age 75 from select causes; includes ischemic heart disease. ** Excludes District of Columbia. DATA: Analysis of 2001–02 and 2004–05 CDC Multiple Cause-of-Death data files using Nolte and McKee methodology, BMJ 2003 SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 H E A LT H Y L I V E S EXHIBIT 30 Mortality Amenable to Health Care by Race, National Average and State Variation, 2004–05 Deaths* per 100,000 Population White Black Overall U. S. Average = 96 250 219 200 183 173 150 100 92 96 86 82 72 50 0 National average Top 5 states average All states median Bottom 5 states average * Age-standardized deaths before age 75 from select causes; includes ischemic heart disease. Note: Top 5 states refer to states with smallest gaps between overall U.S. average and black. Bottom 5 states refer to states with largest gaps between overall U.S. average and black. DATA: Analysis of 2004–05 CDC Multiple Cause-of-Death data files using Nolte and McKee methodology, BMJ 2003 SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 states, compared with 135.4 per 100,000 persons in into thousands of lives. If all states improved to the the bottom states (Exhibit 29). States in the Upper levels achieved by the best state, about 78,000 fewer Midwest, the Mountain region, and New England premature deaths would occur each year. generally had lower rates of mortality amenable to Wide differences exist between amenable mortality health care than states in the South. This gap translates rates for black and white populations (Exhibit 30). In 53 half of the states, rates of death among blacks are at blacks; these states also have highest amenable death least two times higher than among whites. Even in rates in the country. the five states with the lowest amenable death rates Yet even when looking at potentially prevent- among blacks, 92.0 deaths per 100,000 blacks occur able death rates among whites only, wide variation on average—a rate that is higher than the national persists across states. Such rates ranged from a low of average for the white population. 61 to 69 per 100,000 whites in the five states with the Potentially preventable deaths among whites have lowest rate (Minnesota, Utah, Alaska, Vermont, and gone down in nearly all states. Although such rates Nebraska) to a high of 108 to 111 in the five highest- also declined among blacks in many states with sub- rate states (Mississippi, Arkansas, Oklahoma, Nevada, stantial black populations, they have typically done and West Virginia). so at slower rates. As a result, race differences within Higher rates of uninsured residents are also linked states have increased (Exhibit A15). to poorer health outcomes across states. After restrict- High rates of black mortality bring up the average ing the analysis to whites (as a control for race), the mortality rate for states with high concentrations State Scorecard finds the likelihood of dying from con- of black populations, particularly the District of ditions amenable to health care tended to be higher Columbia and states located in the southern central in states with the largest percentages of uninsured regions. Louisiana, Mississippi, and Arkansas have adults (Exhibit 31). The quartile of states with the more than 120 additional deaths per 100,000 black highest uninsured rates among whites averaged an residents in excess of the total national average for additional 20 preventable deaths per 100,000 whites H E A LT H Y L I V E S EXHIBIT 31 Preventable Mortality and Uninsured Rates Among Whites, by State, 2004–05 120.0 WV NV AR OK MS KY TN LA White mortality amenable to health care, deaths* per 100,000 white population 100.0 AL OH IN MO GA TX SC PA NC MD MI DE AZ RI IL NY CA NM NJ VA FL 80.0 KS IA MA ME SD ID WY OR HI WI NH CT CO WA MT ND VT AK NE UT MN 60.0 R2 = 0.29 DC 40.0 5.0 10.0 15.0 20.0 Percent white uninsured, ages 0–64 * Age-standardized deaths before age 75 from select causes; includes ischemic heart disease. DATA: Percent uninsured—2005–06 Current Population Survey ASEC Supplement; Mortality amenable—Analysis of 2004–05 CDC Multiple Cause-of-Death data files using Nolte and McKee methodology, BMJ 2003 SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 54 than the quartile of states with the lowest uninsured to early detection and treatment services, particularly rates (94 deaths per 100,000 vs. 74 per 100,000). This among underserved communities. association between a state’s uninsured rate and its I n fa n t M o r ta l i t y mortality rate remains significant after adjusting for the poverty rate (data not shown). High infant death rates in many states continue to be Comparisons of state rates of deaths amenable of concern. Alarmingly, such rates are up in states that to health care and overall ranking on potentially already had high rates in the earlier State Scorecard. avoidable hospital use/costs dimension reveal a Infant mortality rates increased by at least 5 percent strong correlation (Exhibits 29 and 18).29 The rela- in 22 states and went down by 5 percent or more in 11 tionship points to the potential for states to pursue states, including some states that already had among the twin goals of a healthier population and a more the lowest rates (Exhibit A14). As a result, the spread efficient health care system—with an emphasis on across states grew larger. improving public health as well as the performance The following states, along with the District of of care systems. Columbia, had high rates of infant deaths in 2002 and experienced further increases by 2005: Mississippi, C a n c e r D e at h s South Carolina, Alabama, and Delaware. Their infant Mirroring overall amenable mortality rates, median deaths rates now range from more than 13 per 1,000 state death rates from breast cancer and colorectal live births (District of Columbia) to nine per 1,000 cancer declined between 2002 and 2005. The age- births (Delaware)—all well above the national average adjusted rate of colorectal cancer deaths dropped in of 6.9 per 1,000. Even some previously top-ranked nearly every state, whereas the change in breast cancer states had increases in their infant death rates. Utah death rates was more varied and less pronounced and Washington, on the other hand, are examples of across states (Appendix Exhibit A14). Within states, states with relatively low infant mortality rates in 2002 reducing mortality rates for one type of cancer did not that continued to move ahead of other states by 2005. necessarily overlap with reducing rates for another The highest infant death rates (in the District of type. For example, Wyoming had the largest reduction Columbia, Mississippi, Louisiana, South Carolina, in colorectal cancer death rates (by 5.4 per 100,000 and Alabama) are more than twice as high as the population) during the course of three years, but rates lowest infant death rates (in Utah, Massachusetts, of breast cancer deaths among its residents increased Minnesota, Washington, and New Jersey). Death over the same period. Likewise, Idaho showed the rates among black infants exceed those among white greatest decline in breast cancer deaths (by 6.0 deaths infants in all states—by up to three times in certain per 100,000 population) but made no improvement states that have reliable black infant mortality data. in reducing colorectal cancer deaths. While it is important to consider state variation in Breast cancer mortality ranged from an average racial makeup in assessing state patterns, states with of 19.5 to 28.3 per 100,000 females in the top- and traditionally low or high infant mortality rates persist bottom-five states. This variation has grown smaller at the same relative levels, even after adjusting for as states with the highest breast cancer death rates state racial and ethnic demographics.30 experienced steeper declines than leading states. The states with the lowest white infant mortality The spread in state-specific rates of colorectal cancer rates (excluding the District of Columbia) also tend mortality also narrowed during this time; bottom- to have better birth outcomes for black infants ranked states are now at the median state rate observed relative to all states. Yet, the combined average of in 2002. Still, death rates from colorectal cancer are infant deaths is 4.1 per 1,000 white births versus more than 40 percent higher in the five states with 10.4 per 1,000 black births in these same states. the worst mortality rates, compared with the five Ensuring that high-risk mothers and newborns states with the best mortality rates (20.4 vs. 14.3 per receive appropriate counseling and coordinated care 100,000 population). State strategies should focus on services could improve birth outcomes to the levels increasing screening rates as well as improving access that should be attainable for all infants. 55 Suicides activities because of health problems; in the worst states, the rate reached a high of more than 20 percent Lives lost from suicide present major public health of the working-age population in 2006–07. State ini- and clinical challenges. After a decline of more than tiatives that promote healthy behaviors and curtail a decade, the national suicide rate has gone up since tobacco use and reduce obesity have the potential 1999. From 2003 to 2005, there was no improvement to improve population health substantially. Such in the state median suicide rate or spread across states. strategies could also lead to real cost savings. Between Age-adjusted suicide rates continue to vary consid- 2000 and 2004, cigarette smoking resulted in annual erably across states, from a low of six per 100,000 direct medical costs of approximately $96 billion—or persons in New York and New Jersey (and 5.5 per a total of $193 billion annually if lost productivity is 100,000 in the District of Columbia) to a high of included.33 Meanwhile, the annual medical costs of 20 or more per 100,000 in Montana, Alaska, and obesity alone have doubled in the past decade, adding Nevada. Regional patterns reveal that suicides are $147 billion to the nation’s health care bill in 2008.34 most common in states from the Mountain region, Smoking rates among adults showed signs of im- and rates have slipped farther behind in Montana and provement, decreasing by 5 percent or more in 40 Colorado. Wyoming, with historically high rates of states from 2003–04 to 2006–07. Yet, large geographic suicide, exhibited the greatest improvement (by 4.6 variations exist. The highest percentages of smokers per 100,000 population). Suicide death rates were are concentrated in the South-Central region and lowest in the Northeast. lower Midwestern states. On average, more than one Recent studies find that lower state-based suicide of four adult residents smoke in the bottom-ranked rates are related to positive indicators of access to and states of Kentucky, West Virginia, Oklahoma, Mis- utilization of mental health care services, including sissippi, and Indiana, compared with only one of 10 lower rates of uninsured residents.31 Notably, the in Utah, the top-ranked state (Appendix Exhibit 14). five states ranked highest by the State Scorecard Those states with the highest adult smoking on the access dimension have a combined average rates also continue to have relatively low excise suicide rate that is almost 40 percent lower than the taxes, despite the proven effectiveness of such levies combined average of the five lowest-ranked states. in preventing smoking initiation and reducing New state-level data from the National Survey of cigarette consumption. In fact, seven of the top 10 Drug Use and Health show wide variation among states with the lowest smoking rates have cigarette the states in the proportion of adults who had a taxes of at least $2.00 per pack. Notably, Rhode major depressive episode and received any mental Island, which back in 2003 became one of the health treatment in the past year (see table 3A in first two states to achieve the Healthy People 2010 supplemental State Scorecard Data Tables). Rates objective of $2.00 per pack, is now one of the most of reported treatment ranged from 77 percent in improved states on this indicator.35 This year, Rhode the best state (Connecticut) to only 50 percent in Island increased its cigarette tax to $3.46 per pack, the worst state (Arizona) during 2004–07. Other the highest in the nation.36 research has found that even when people receive The prevalence of childhood overweight (defined mental health treatment, it is often inadequate in as greater than or equal to the 85th percentile of body achieving health outcome goals.32 This indicator will mass index, or BMI, based on gender, age, weight, and be included in future State Scorecards as time trends height) or obesity (95th percentile of BMI or higher) become available. has failed to show marked improvements from 2003 to 2007. At least a quarter of children ages 10 to 17 P u b l i c H e a lt h are overweight or obese in every state, except Utah, Smoking and obesity contribute to high rates of pre- Minnesota, and Oregon (although these states are not ventable disease and long-term disability, as well as far behind). In 17 states, one of three children is either risk of early death. In the majority of states, an in- overweight or obese. Such lack of progress suggests creasing proportion of adults are limited in their daily that obesity-related hospitalizations among children 56 and youth will continue to rise and drive Medicaid • Wide variations in access, quality, costs, and health costs as they have been doing.37 outcomes persist across states. Notably, regional patterns of childhood over- • Improvement in key areas of quality performance weight or obesity prevalence closely resemble those holds promise for continued improvement in these of mortality amenable to health care rates. States in and other areas of performance. the South-Central region have the highest percent- • Symptoms of poor care coordination and inef- age of overweight or obese children, and parts of ficient use of resources point to opportunities to the Upper Midwest, the Mountain region, and New improve the quality of care and reduce costs. England have the lowest. Geographic disparities have • Affordability of care is a concern across states. remained even after adjusting for individual and • There is room for improvement across all states. area-level socioeconomic factors.38 By 2007, Missis- Leading states consistently outperform sippi had the highest rate of overweight and obesity, lagging states across indicators and growing from 37 percent of children to a staggering dimensions: public policy and public–private 45 percent. Previously top-ranked states also show collaboration can make a difference. higher rates of childhood overweight or obesity. Thirteen states—Vermont, Hawaii, Iowa, Minnesota, Reducing obesity and smoking rates would sig- Maine, New Hampshire, Massachusetts, Con- nificantly raise health outcomes and quality of life. necticut, North Dakota, Wisconsin, Rhode Island, Improvement in these areas requires comprehen- South Dakota, and Nebraska—again rise to the top sive strategies, including public health initiatives to quartile of the overall performance rankings (Exhibit provide nutrition counseling, smoking cessation, 1). Though specific rankings shifted, these are the and exercise programs, along with enhanced same states that were identified as top performers access to care for the most disadvantaged groups. in the first State Scorecard two years ago. Many have A number of states are already using a variety of been leaders in health system reform, including incentives in state-funded programs like Medicaid targeted efforts to reduce rates of uninsured adults and CHIP to encourage healthy behaviors.39 State and children. efforts can be further boosted by a federal commit- Ten of the 13 states in the lowest quartile of per- ment to disease prevention and health promotion, formance— Tennessee, Alabama, Florida, Kentucky, such as recent legislation authorizing the Food Texas, Nevada, Arkansas, Louisiana, Oklahoma, and and Drug Administration to regulate the content, Mississippi—also ranked in the bottom quartile in the marketing, and sale of cigarette and tobacco 2007 State Scorecard. Three others—North Carolina, products.40 Indeed, public policy interventions Illinois, and New Mexico—dropped from the third to that helped bring down tobacco use—excise taxes, the fourth quartile, while California, West Virginia, warning label requirements, and advertising bans— and Georgia moved up out of the last quartile. The may offer models for addressing the ever-growing 13 states in the lowest quartile lagged well behind public health problem of obesity.41 their peers on indicators across performance dimen- sions. Rates of uninsured adults and children are, on Cross-Cutting Findings average, double those in the top quartile of states. S Receipt of recommended preventive care is generally ix cross-cutting findings emerge from the lower, and mortality from conditions amenable to 2009 State Scorecard, some of which reinforce health care is 50 percent higher on average in these themes identified in the 2007 State Scorecard states than in leading states. and some of which are new: Among the states that moved up the most in • Leading states consistently outperform lagging the overall rankings, Minnesota rose within the top states across indicators and dimensions: public quartile of performance to become the fourth-ranked policy and public–private collaboration can make state, with significant improvement on multiple in- a difference. dicators. In three states—Arkansas, Delaware, and 57 West Virginia—plus the District of Columbia, at Geographic variations remain striking, repeating least half of the performance indicators improved by the same general patterns seen in the first State 5 percent or more (Appendix Exhibit A3). Leading Scorecard. Upper Midwest and New England states set new benchmarks for 20 of the 35 indicators states continue to lead, and states across the South, with trends. Southwest, and Lower Midwest continue to trail their These patterns indicate that public policies, as peers on overall performance rankings. This pattern well as state and local health care systems, can make generally holds for the access, quality, and equity a difference, though socioeconomic factors also play a dimensions, but western states tend to perform better role. Vermont, Maine, and Massachusetts, for example, on the other two dimensions (avoidable hospital use have enacted comprehensive health system reforms to and costs of care and healthy lives) (Exhibit 1). Yet, expand coverage and also have initiatives under way to exceptions also exist—especially where states and improve population health and benchmark providers care systems have made a concerted effort to improve. on the quality of care they deliver. Minnesota is a Improvement in key areas of quality leader in bringing public- and private-sector stake- performance holds promise for holders together in collaborative initiatives to improve continued improvement in these and the overall value of health care—an approach that is other areas of performance. gaining traction in other states as well.42 As New York The 2009 State Scorecard also documents widespread and Utah have made concerted efforts to improve their improvement across states for selected indicators, performance in priority areas, their performance on especially quality indicators for which there has been key indicators has improved.43 a national commitment to reporting performance Wide variations in access, quality, costs, and data and collaborative efforts to improve. Notably, health outcomes persist across states. for some indicators of hospital clinical processes, Overall, the range of performance remains wide the average performance of the bottom-ranked states across states and dimensions of performance, with a now exceeds the median state rate three years ago— twofold to threefold spread between top and bottom as virtually all states improved (Exhibits 2 and 3). states on multiple indicators (Exhibit 2). On many These indicators measure treatment for heart attack, indicators, the leading states have improved sub- heart failure, and pneumonia, prevention of surgical stantially since the 2007 State Scorecard—setting complications, and provision of written discharge new benchmarks. instructions for heart failure patients. The range across states is particularly wide on Performance on publicly reported measures the following indicators: percent insured; rate of of nursing home care quality also improved sub- diabetic patients receiving recommended care; receipt stantially across states. The average performance of mental health care for children; rate of pressure on reported pain and use of physical restraints on ulcers in nursing homes; rate of preventable hospital residents improved by at least 5 percent in all states, admissions; and mortality amenable to health care. and in the majority of states average performance To reach the level of top-performing states, bottom- improved by the same amount for a measure of performing states would need to improve by 40 to pressure ulcers; in addition, the range of perfor- 50 percent on average. mance between states narrowed. One key measure of Improving the performance of all states to home health care quality—improvement in patients’ the levels achieved by the best states could save mobility—also showed a 5-percent-or-greater im- thousands of lives, improve access to care and quality provement in most states. of life for millions, and reduce costs to pay for Currently, all hospitals are required to publicly improved care and expanded coverage. As discussed report selected indicators in return for payment under “Impact of Improved Performance,” below, updates from Medicare. Several public and private the cumulative effect would mean substantial gains initiatives have further tied payment incentives to im- in value to the nation. provement on such metrics. The rapid improvement 58 in a relatively short period illustrates the importance or more on only 15 such indicators, and these were of having performance information to guide and drive mainly in the prevention and treatment quality change. It also shows that health care providers have dimension (Appendix Exhibit A2). Disturbingly, the capacity to improve and that financial incentives the range of performance across states widened on can foster higher performance. In contrast, hospital a third of these indicators—often in tandem with a readmission rates and several quality indicators that decline across states. are not generally publicly available at the level of Making positive change the norm across all indica- health care delivery systems failed to improve or tors and states will require federal action and com- evidenced mixed performance across states. prehensive reforms to raise the floor on performance General trends toward lower rates of mortality levels. It also will require state policies that ensure amenable to health care, cancer deaths, and smoking access to care, realign provider incentives, and provide are also promising. Still, most states’ death rates sub- performance information and targets to improve. stantially exceed those achieved by the lowest state benchmarks. The more than twofold spread among Symptoms of poor care coordination and inefficient use of resources point states on rates of mortality amenable to care and to opportunities to improve the smoking, and the greater than 50 percent spread on quality of care and reduce costs. breast cancer and colorectal cancer deaths, signal that there are significant opportunities to improve, The State Scorecard findings of gaps in quality and particularly through efforts focusing on population fragmented care are symptomatic of health system health and outcomes. dysfunction. All too common are failure to provide At the same time, rates of childhood overweight timely and effective preventive and chronic care, or obesity have yet to show any meaningful declines. increases in or failure to reduce hospital readmis- Further progress in reducing unnecessary death sion rates, and rising rates of hospital admissions and illness will hinge on prevention of disease and from nursing homes and home health care. Despite promotion of healthy behaviors in both medical and improvement in some states, rates of potentially community settings. Clinical care systems need to preventable hospitalizations remain high in many work hand in hand with public health profession- states. Low rates of recommended care delivered als and community-based groups to implement in community practices underscore the need for a programs and policies and evaluate progress toward stronger primary care infrastructure. achieving population health goals.44 Annual costs of care (average employer-group Gains in the quality of care provided in hospitals premiums for individuals and Medicare spending per and nursing homes were not matched in other areas. beneficiary) vary widely across states, with no system- Of particular concern, there were modest increases atic relationship to insurance coverage or ability to in the percentage of adults receiving preventive care pay (as measured by median income). Moreover, there in just half the states and failure to improve in the is no systematic relationship between performance majority of states on multiple indicators of ambula- on cost and quality indicators across states. Some tory care quality and access over the two-to-four- states in the Upper Midwest (e.g., Iowa, Minnesota, year trends typically captured by the 2007 and 2009 Nebraska, North Dakota, and South Dakota) achieve State Scorecards. Performance on many indicators of high quality at lower costs. Although these states are avoidable hospital use and costs failed to improve or exceptions, they provide examples for other states grew worse, especially rates of hospital admissions and to follow. readmissions from nursing homes—highlighting the States with higher medical costs tend to have need for better coordination of care across settings. higher rates of potentially preventable hospital use, The median state rate (representing the middle of including high rates of readmission within 30 days of the range) failed to improve or declined by 5 percent discharge and high rates of admission for complica- or more on 20 of the 35 indicators for which trends tions associated with diabetes, asthma, and other were available. There was improvement of 5 percent chronic conditions. Reducing the use of expensive 59 hospital care by preventing complications, controlling coupled with evidence that rapid improvement is chronic conditions, and providing effective transi- possible when there are incentives in place for the tional care following discharge has the potential to public reporting of such data—underscore the need improve outcomes and lower costs. for the federal government to work in tandem with states to create coherent, all-population information Affordability of care is a concern across states. systems that furnish essential data and performance Across the country, health care costs have been targets. Federal efforts are also essential to spur the rising faster than incomes. As a result, insurance adoption and effective use of interoperable health premium costs have increased as a share of income for information technology, so that clinicians have the middle-income families in most states. The upward tools and decision support they need to provide safe, pressure has led to erosion of insurance benefits, effective, and efficient care. with growing numbers of “underinsured” individu- The wide variation in costs and symptoms of als—those who are poorly protected in the event of less-efficient care systems further point to the im- illness even though they are insured all year long—as portance of federal leadership in payment reform. well as loss of coverage.45 Notably, the 2009 State With Medicare payments accounting for a substantial Scorecard data on access to care predate or capture share of revenues for hospitals and physicians, federal only the early phase of the economic recession, which payment reforms—including Medicare participation has likely worsened coverage trends across states. in statewide all-payer efforts—could promote signifi- Reversing the trends will require a dual focus on cant gains in quality and efficiency. On a foundation “bending the cost curve” as well as action to secure of more-affordable coverage for everyone, with federal affordable coverage for all. reforms to assure affordable coverage for all, effective There is room for improvement across all states. use of information systems, and payment reform All states have substantial room to improve. No state could help all states aim higher to improve access ranked in the top quartile across all indicators. Even and health outcomes, and, at the same time, slow the among the top-ranked states, each had several indica- rate of cost growth. tors that declined by 5 percent or more and each had Impact of Improved Performance T some indicators in the bottom quartile or lower half of the performance distribution (Appendix Exhibits here are many ways to improve health A1 and A3). Moreover, even the best performance system performance, involving stakehold- on some indicators is well below what is achievable ers at all levels of the system. This section based on the benchmarks set by top-performing illustrates the potential gains in terms of healthy health care systems. lives, access, and dollars if all states were able to Improvement is possible for all states. Each of meet the levels of performance achieved by top the lowest-ranked states exhibited pockets of high states for selected indicators. It concludes with a performance or improved significantly on certain discussion of policy implications for federal and indicators. There is value in learning from the expe- state governments. riences of those states or care systems that face the Exhibit 32 shows the estimated impact if all states greatest challenges. were to improve their performance to the rate of the At the same time, the wide variation across states best-performing state for 11 key scorecard indicators.46 and common concerns with care coordination and If all states could approach the low levels of mortality rising costs point to a need for national reforms from conditions amenable to health care achieved by that stimulate and support state-based improve- the top state in 2004–05, there would be nearly 78,000 ment initiatives. The disparities in access across fewer deaths before age 75 on an annual basis. There states signal the need for federal action to raise the also could be potentially fewer disease complications floor for insurance coverage by extending affordable and limitations in activities of daily living through coverage to everyone. Gaps in performance data— improved access to care and timely delivery of care. 60 If all states in the U.S. performed at the levels extended to all patients. Over $1 billion dollars could achieved by the top states: potentially be saved through a reduction in hospital admissions by providing the standard of care for • about 29 million more adults and children would frail nursing home residents reached in the best- have health insurance coverage—reducing the performing state. Savings would be contingent on number of uninsured by more than half; identification of effective interventions, and some • approximately 9 million more adults age 50 and savings might be offset by the costs of the interven- older would receive preventive care, including tion. More generally, the nation would save $20 billion cancer screenings and immunizations; to $37 billion per year if higher-cost states achieved • nearly 4 million more diabetic patients would access, care, and efficiency improvements sufficient receive basic recommended care to help prevent to bring costs down to the national median or rates or delay the onset of disease complications; and achieved by the lowest-cost quartile of states. • about 30 million more adults and children would These examples illustrate only a few of the many have a regular source of primary care and care important opportunities for improvement. Because coordination. some indicators would affect the same individuals, The Medicare program could potentially save some of these numbers cannot be combined. Yet, $2.9 billion to $5.0 billion a year by reducing poten- across states over the course of several years, the tially preventable hospitalizations for chronically numbers add up to substantial gains in value for ill Medicare patients or by reducing the number of the nation. readmissions by improving care transitions. These savings would be even greater if the improvements ExHIBIT 32 National Cumulative Impact if All States Achieved Top State Rate If all states improved their performance to the level of the Indicator best-performing state for this indicator, then: Insured Adults 24,080,100 more adults (ages 18–64) would be covered by health insurance (public or private), and therefore would be more likely to receive health care when needed. Insured Children 5,363,021 more children (ages 0–17) would be covered by health insurance (public or private), and therefore would be more likely to receive health care when needed. Adult Preventive Care 9,005,926 more adults (age 50 and older) would receive recommended preventive care, such as colon cancer screenings, mammograms, pap smears, and flu shots at appropriate ages. Diabetes Care 3,941,224 more adults (age 18 and older) with diabetes would receive three recommended services (eye exam, foot exam, and hemoglobin A1c test) to help prevent or delay disease complications. Childhood Vaccinations 786,471 more children (ages 19–35 months) would be up-to-date on all recommended doses of five key vaccines. Adults with a Usual Source of Care 21,017,920 more adults (age 18 and older) would have a usual source of care to help ensure that care is coordinated and accessible when needed. Children with a Medical Home 8,732,905 more children (ages 0–17) would have a medical home to help ensure that care is coordinated and accessible when needed. Preventable Hospital Admissions 746,484 fewer hospitalizations for ambulatory care sensitive conditions would occur among Medicare beneficiaries (age 65 and older) and $5.0 billion dollars would be saved from the reduction in hospitalizations. Hospital Readmissions 209,723 fewer hospital readmissions would occur among Medicare beneficiaries (age 65 and older) and $2.9 billion dollars would be saved from the reduction in readmissions. Hospitalization of Nursing Home 127,393 fewer long-stay nursing home residents would be hospitalized and Residents $1.0 billion dollars would be saved from the reduction in hospitalizations. Mortality Amenable to Health Care 77,952 fewer premature deaths (before age 75) might occur from causes that are potentially treatable or preventable with timely and appropriate health care. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 61 Aiming Higher: The Need for improvements. And states where a large propor- tion of residents are uninsured face a much higher Action to Improve Performance hurdle in seeking to enact comprehensive reform than I n the midst of the current national debate states with a relatively small number of uninsured. on health system reform, the State Scorecard Moreover, the experience of the economic recession provides states with a framework for taking highlights the challenges of “going it alone”—even for stock of how they are performing and where they states at the top of scorecard rankings. have opportunities to improve. The erosion in health Hence, a cogent and congruent set of national and insurance coverage (with the notable exception of state policies is needed to move the country further a few states) and the high uninsured rates in many along the path to higher performance. Disparities states underscore the need for national reform and across states point to the importance of federal action federal action to extend affordable insurance and that raises the floor on performance levels across ensure access for everyone. all states and creates a supportive climate for state Federal and national reforms also are needed to innovation and achievement. enable all-population data, spread the adoption and The Commonwealth Fund’s Commission on a effective use of health information technology, and High Performance Health System has identified five initiate payment reforms. The Medicare program, as essential strategies for comprehensive reform. States the single-largest payer of hospitals and physicians, can play an important role in fulfilling these aspira- has the ability to serve as a national leader in the area tions as part of a broader national effort. of payment reform. 1. Affordable coverage for all; The State Scorecard reveals that the U.S. health care 2. Align incentives with value and effective cost system often fails to provide timely and effective pre- control; ventive and chronic care, or to ensure safe and effective 3. Accountable, accessible, patient-centered, and care transitions. High rates of potentially preventable coordinated care; hospitalizations and readmissions in many states and 4. Aim high to improve quality, health outcomes, low rates of receipt of recommended preventive care and efficiency; and in the community underscore the need for a stronger 5. Accountable leadership and collaboration to set primary care infrastructure and a clear focus on popu- and achieve national goals. lation health to help prevent and reduce the burden of chronic disease. Further, growing obesity rates call for Individual states continue to make progress to greater effort at integrating medical and public health improve access to health care as well as health care interventions to support individuals in adopting and quality and equity. The specific innovations that maintaining healthy lifestyles. have gained traction since the last State Scorecard are States play many roles in the health system: increased access to care through coverage expansions, purchasers of coverage for vulnerable populations use of information exchanges and other technology and for their employees; regulators of providers and to share patient and other health data, and a strong insurers; advocates for public health; and, increas- emphasis on management of chronic conditions ingly, conveners and collaborators with other stake- through payment incentives and medical homes. holders. States also have multiple opportunities to Aff o r d a b l e Co v e r ag e f o r A l l convene stakeholders to collaborate on improvement and to provide leadership that will hold care systems In addition to working toward comprehensive accountable for population health and affordability. coverage reforms, states can make health insurance Even at their best, however, states cannot do all more affordable and efficient through effective the work of reform on their own. States challenged oversight and reform of health insurance markets by high rates of disease and poverty, as well health and through value-based purchasing of coverage care systems that are low-performing, often are the for state employees. Expanding eligibility for and most limited in the resources available to invest in improving provider payment under both Medicaid 62 and CHIP would support greater participation and Given states’ current fiscal duress and their failure access for vulnerable populations. to enact comprehensive reforms in the years before One of the most notable health policy reforms the recession, it is unlikely that many will succeed of the past year was the passage of the Children’s in getting close to universal coverage on their own. Health Insurance Program Reauthorization Act To support state efforts, strong federal action, (CHIPRA) by Congress on February 4, 2009. The including a common insurance coverage framework legislation provides an additional $33 billion over and financing, is needed—especially for states that four-and-a-half years, primarily through increased face large coverage gaps and socioeconomic chal- tobacco taxes, to cover up to 6.5 million newly lenges. By moving from fractured to continuous enrolled children under CHIP and Medicaid, insurance coverage, comprehensive reform would assuming that states are able to provide matching provide a more coherent and effective foundation funding. An estimated 4.1 million of these 6.5 for payment and system reforms to enhance quality million children would remain uninsured without and efficiency. this action. States that streamline enrollment and A l i g n I n c e n t i v e s w i t h Va lu e retention procedures for the CHIP program will a n d Eff e ct i v e Co s t Co n t r o l receive a federal bonus payment for each child enrolled above a target level.47 The U.S. health system’s reliance on fee-for-service Rhode Island, for example, has responded to reimbursement creates incentives for providers to CHIPRA with an increased state allotment for increase the volume of services they deliver—ir- its RIte Care and RIte Share programs to expand respective of the value of that care. This system of coverage and premium assistance to children and payment undermines efforts to improve quality and pregnant women up to 300 percent of the federal efficiency. The Commonwealth Fund’s Commission poverty level. The state is utilizing the federal law’s on a High Performance Health System estimates new “Express Lane” option, which allows Medicaid that payment reforms, coupled with universal health programs to use eligibility determinations made by coverage and other system reforms, could slow the other public agencies.48 growth of health spending by a cumulative $3 trillion A few leading states have expanded coverage through 2020, compared with projected trends in as part of comprehensive health system reforms. the absence of reform.53 In Massachusetts, 428,000 residents have gained In its 2009 report to Congress, the Medicare coverage since late 2006 through a combination of Payment Advisory Commission (MedPAC) recom- policies involving shared responsibility among in- mends a move toward reimbursing providers with dividuals, employers, government, and insurers.49 more “bundled” payments for services, associated As a result, 97.4 percent of Massachusetts’ residents with care received over time to encourage efficiency now have health insurance coverage—the highest and accountability for outcomes. The report also rate in the nation.50 Vermont’s Catamount Health recommends making additional payments to primary Care Plan and Maine’s Dirigo Health program also care practices to support patient-centered “medical offer promising models for attaining universal or homes” to improve care for those with chronic condi- near-universal coverage. tions. States and private insurers also are looking to Other states are pursuing incremental approaches make payment reforms to improve the value of care. to fill in coverage gaps. Wisconsin’s BadgerCare Plus, A report from the Center for Health Care Strategies for example, is a new state health insurance plan that finds that more than half of all states currently operate aims to cover more than 40,000 childless adults with one or more pay-for-performance programs for their incomes below 200 percent of the federal poverty Medicaid programs, and nearly 85 percent expect to level.51 A new Oregon law will provide coverage for do so over the next five years.54 CHIPRA establishes a 80,000 uninsured children and 35,000 low-income new Medicaid Commission modeled after MedPAC adults funded by a tax on insurers and hospitals as to evaluate children’s access to care and payment well as increased federal funds.52 policies in Medicaid and CHIP.55 63 Several states are looking to multipayer initiatives For example, a State Quality Improvement Institute, to move in the same direction, with an emphasis on sponsored by The Commonwealth Fund and led by value and on bending the cost curve. For example, AcademyHealth, is intended to help states share best in Massachusetts, a special commission recently practices and implement concrete efforts to improve recommended that all payers in the state transi- health system performance.59 tion to the use of “global fees” that “prospectively Massachusetts has developed a chronic care compensate providers for all or most of the care that management model that brings together public and their patients may require” over a given period, with private health care leaders to promote coordinated, adjustments to “reward provision of accessible and integrated care through medical homes statewide. high quality care.”56 New Jersey is looking to expand Payment reform is a key strategy for aligning quality an “Accountable Care Organization” approach that measurement and payment for primary care phy- targets efforts to improve outcomes and reduce costs sicians. Additional planned interventions include for those with very high health risks and high-cost, educating primary care providers about evidence- low-income families. based diabetes care standards, creating a diabetes Providing financial support for the development patient registry, and working with the Department of of primary care medical homes is another way to Health to launch a consumer education campaign.60 develop structural changes and financial incentives Vermont’s Blueprint for Health is seeking to that can lead to quality and efficiency improvements develop capacity at the community level to improve through better coordination of care.57 Minnesota care coordination for chronically ill residents—a passed legislation promoting this model in 2008. potential model for other states.61 North Carolina’s Under the legislation, health care homes, which can Community Care of North Carolina has invested include physicians, advanced nurse practitioners, or in nurse care manager networks and primary physician assistants, will receive care coordination care physician practices to promote the sharing payments of about $50 per patient from public and of resources and team care across the state. This private health care purchasers to cover the costs of approach has reduced use of hospitals and emergency managing patients with complex chronic conditions.58 rooms and improved health outcomes.62 Aligning incentives among federal Medicare, Several multipayer, public–private collaboratives state Medicaid, and private insurance plans could are focusing on improving quality, coordination, enhance the effects of payment reforms. The federal and accountability. Pennsylvania is targeting care government recently announced that the Centers for childhood asthma and adult diabetes within 32 for Medicare and Medicaid Services will establish a group practices, including seven federally qualified demonstration program under which Medicare will health centers; 16 commercial payers are participat- join Medicaid and private insurers in state-based ini- ing. In Rhode Island, collaboration among Medicaid, tiatives that integrate patient-centered medical homes Medicare, and commercial payers is offering shared and public health services to promote the efficient support for nurse care managers embedded in clinical delivery of high-quality care with an emphasis on practice sites to foster medical homes, with a focus on wellness and prevention. diabetes, depression, and coronary artery disease.63 CHIPRA includes $225 million over five years Acco u n ta b l e , Acc e s s i b l e, Pat i e n t - for health quality initiatives. The federal Agency C e n t e r e d, a n d Co o r d i n at e d C a r e for Healthcare Research and Quality and Centers Improvements achieved by hospitals and nursing for Medicare and Medicaid Services are working to homes underscore the value of reaching consensus develop an initial core set of quality measures for on national standards, setting goals for improvement, children by 2010 for voluntary use by Medicaid and and benchmarking performance among peers to CHIP providers. The law also establishes a program stimulate competition and achieve results. Collabora- for the creation and dissemination of a model elec- tive learning and technical assistance can help states tronic health record for children and creates a dem- create the necessary infrastructure for improvement. onstration program to reduce childhood obesity.64 64 A i m H i g h to I m p r o v e Q ua l i t y, free electronic access to medical claims history, H e a lt h O u tco m e s , a n d Eff i c i e n c y including lab test results, and enables electronic prescribing to pharmacies.70 Federal funds support Widespread adoption of electronic medical records and electronic information exchange among the initiative. providers, along with the redesign of care processes Meanwhile, such states as California, New York, to support more effective and efficient care delivery, Pennsylvania, and Utah have led robust efforts to could save the nation an estimated $88 billion deploy public reporting and data monitoring systems over 10 years.65 States such as New York have es- that serve as models for the states: tablished programs to promote innovative use of health information technology (HIT) to improve • Pennsylvania recently implemented new laws to health care. Such efforts will be strengthened by the provide transparency in reporting quality data Health Information Technology for Economic and and rates of health facility–acquired infections. In Clinical Health Act (HITECH), which was part of the first six months, this effort contributed to a 7.6 the federal economic stimulus legislation. Along percent decrease in hospital-acquired infections with financial incentives for providers, HITECH and 300 fewer deaths related to such infections offers state planning grants and loans to support and compared with the previous year.71 expand the effective statewide use of HIT and health • Utah’s Health Data Authority Act created a Health information exchanges (HIE).66 For example: Data Committee, representing multiple stake- holders and staffed by an Office of Health Care • Minnesota, which has long focused on information Statistics, that is charged with collecting, analyzing, exchange as a means of improving outcomes and and distributing health care data to facilitate the reducing costs, has a not-for-profit HIE organiza- promotion and accessibility of quality and cost- tion with a public–private governance structure. effective health care.72 The exchange serves 3.9 million patients and is designed to share clinical and administrative data Information is critical to guide and drive change, among multiple providers in Minnesota and bor- and to set targets and monitor progress over time. dering states.67 Medicare is currently the only national source of • Arizona is incorporating HIE into its Medicaid data available for tracking several important indica- program to promote efficient, patient-centered tors of performance across all states. More robust care. Starting in pilot regions in 2008, providers are national data are essential for assessing performance able to exchange patient demographic, eligibility, comprehensively for all payers, including Medicaid and clinical information. The state is also creating and private insurers. Notably, although hospital a group purchasing arrangement for providers to readmission rates offer a target for improvement acquire systems that will support statewide objec- that could bring about broad systems changes, most tives for the effective use of HIT.68 states currently lack the data to track or monitor • The five-year-old Indiana HIE connects 39 hos- readmission rates. And federal data comparing geo- pitals and 10,000 physicians to deliver laboratory graphic regions and care systems are not readily or results and medication and treatment histories publicly available. in real time. The Indianapolis HIE estimates that Several states are combining public health initia- it saves $26 per emergency department visit by tives with reforms to improve the health care delivery eliminating duplicate tests and other unnecessary system. These include a focus on community-wide activities. The system also alerts doctors about efforts to lower rates of obesity, tobacco use, and other potential drug interactions and reminds them risks to population health.73 States are in a unique about appropriate preventive services and chronic position to support such community health initiatives disease follow-up care.69 through their ability to convene multiple stakeholders • Alabama is currently testing its QTool health in- as well as their support for public health resources formation system, which provides clinicians with and authority. 65 Acco u n ta b l e L e a d e r s h i p a n d Conclusion T Co l l a b o r at i o n to S e t a n d Ac h i e v e NAT IONAL G o a l s he overall picture that emerges from the State Scorecard is the clear potential for improve- Several leading states have histories of a collaborative ment on all key dimensions of performance. culture of quality improvement focused on improving Our national values emphasize that we are one nation, leadership, transparency, and sustainability of results. yet where people live affects their health care in Such efforts tend to focus on expanding access as well as nearly every respect—access, quality, and afford- quality, with a goal of improving health outcomes. For ability. The view across states reveals startlingly wide example, an initiative led by the Institute for Healthcare gaps between leading and lagging states on multiple Improvement is engaging several states in an effort indicators. Gaps between actual and achieved per- to prove statewide approaches for reducing hospital formance represent illnesses that could have been readmissions. prevented or better managed, as well as dollars that Vermont’s Blueprint for Health Integrated Pilot could have been saved or reinvested to improve Program began in 2008 with three pilot communities population health. Exemplary initiatives in the top- working to reduce the health and economic impacts of performing states and models of excellence in health the most common chronic conditions. This initiative care delivery that exist within many states can help builds on the framework passed in its 2006 health care set the pace for change. reform legislation and revised in 2007. Pilot communi- Continuing variation in state performance also ties are given infrastructure and financial incentives provides compelling evidence of the need for concerted to operate a patient-centered medical home, with the and complementary federal and state policy action to goals of reducing costs through improved efficiency and improve health system performance across all key di- better management of chronic conditions. Vermont’s mensions. National reform can provide a more coherent blueprint also seeks to improve community health and health system infrastructure, so that benchmark levels prevent disease by encouraging healthy lifestyles for achieved by top-performing states become realistic the general population.74 targets for all states to meet and exceed. As part of its involvement in the State Quality Im- Without federal reform to address rising costs provement Institute, Kansas set a goal that 85 percent as well as support more affordable access, coverage of the state’s children have a medical home. In addition, rates and access to care will continue to deteriorate in the state has achieved agreement on indicators of coming years. At the onset of the economic recession, quality, access, cost, and public health—including 1.5 million more adults were uninsured in 2008 than in several measures of the quality of care provided in 2007, putting one in five working-age adults at risk of Medicaid managed care organizations—and has started financial catastrophe from a major illness. This increase publicly reporting results. Kansas also has created a in the uninsured would have been much worse without consumer Web site for comparing the cost and quality a growth in government-provided health insurance of health care plans and providers.75 such as Medicaid and CHIP that covered 4.4 million North Carolina formed the Healthcare Quality people. The rate of uninsured children declined to its Alliance, which is sanctioned by the governor and lowest level since 1987 (the first year that comparable includes a plan to standardize care across the state for data were collected) as a result of an 800,000 decrease diabetes, asthma, hypertension, heart failure, and heart in the number of uninsured children. Private coverage attacks. It is a collaborative effort, one involving North declined for both adults and children.78 Carolina provider organizations, three major insurers, Without national action, the number of uninsured the state employee health plan, and Medicaid.76 The is expected to reach 61 million by 2020, with millions Alliance complements the community-led quality more Americans underinsured. Such a trend is likely improvement initiatives undertaken by Community to overwhelm safety-net providers and undermine the Care of North Carolina, a public–private collaboration financial health of community health systems that serve serving Medicaid and CHIP beneficiaries.77 the entire community. With costs rising faster than incomes and pressuring families and businesses, it is urgent that states and the nation join together to aim higher—to take action to enhance the value of health care across the country and ensure that everyone can partici- pate in the health care system according to their needs. 66 Notes 1 J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, 12 M. J. Koren, “Moving to a Higher Level: How Collaboration Aiming Higher: Results from a State Scorecard on Health System and Cooperation Can Improve Nursing Home Quality,” Invited Performance (New York: The Commonwealth Fund, June 2007); Testimony, U.S. House of Representatives, Committee on Energy Commonwealth Fund Commission on a High Performance and Commerce, Subcommittee on Oversight and Investigations, Health System, Why Not the Best? Results from a National hearing on “In the Hands of Strangers: Are Nursing Homes Scorecard on U.S. Health System Performance, 2008 (New York: Safeguards Working?” May 15, 2008; national and state-by- The Commonwealth Fund, July 2008); and Commonwealth Fund state data through the third quarter of 2008 available from Commission on a High Performance Health System, Why Not Campaign Progress section on the Advancing Excellence Web the Best? Results from a National Scorecard on U.S. Health System site at http://www.nhqualitycampaign.org. Performance (New York: The Commonwealth Fund, Sept. 2006). 13 Commonwealth Fund Commission, Why Not the Best? 2008; 2 S. F. Jencks, T. Cuerdon, D. R. Burwen et al.,“Quality of Medical C. Schoen, R. Osborn, S. K. H. How, M. M. Doty, and J. Peugh, Care Delivered to Medicare Beneficiaries: A Profile at State and “In Chronic Condition: Experiences of Patients with Complex National Levels,” Journal of the American Medical Association, Health Care Needs, in Eight Countries, 2008,” Health Affairs Web Oct. 4, 2000 284(13):1670–76; and S. F. Jencks, E. D. Huff, and T. Exclusive (Nov. 13, 2008):w1–w16; E. S. Fisher, D. E. Wennberg, Cuerdon, “Change in the Quality of Care Delivered to Medicare T. A. Stukel et al., “The Implications of Regional Variations Beneficiaries, 1998–1999 to 2000–2001,” Journal of the American in Medicare Spending, Part 1: The Content, Quality, and Medical Association, Jan. 15, 2003 289(3):305–12. Accessibility of Care,” Annals of Internal Medicine, Feb. 18, 2003 138(4):273–87. 3 Commonwealth Commission on a Health Performance Health System, The Path to a High Performance U.S. Health System: A 14C. Schoen, S. R. Collins, J. L. Kriss, and M. M. Doty, “How Many 2020 Vision and the Policies to Pave the Way (New York: The Are Underinsured? Trends Among U.S. Adults, 2003 and 2007,” Commonwealth Fund, Feb. 2009). Health Affairs Web Exclusive (June 10, 2008):w298–w309. 4 J. Sullivan, CHIPRA 101: Overview of the CHIP Reauthorization 15 Decreases in ACS admissions also have been observed in Legislation (Washington, D.C.: Families USA, March 2009). all-payer data collected by the Healthcare Cost and Utilization Project, a federal–state partnership (data available at http:// 5 R. Knutson, “California Deal Leaves More Kids Uninsured,” Wall hcupnet.ahrq.gov/). An investigation found that changes in Street Journal (Aug. 1, 2009). claims coding may have been a factor in rates of hospitalizations 6 S. K. Long and P. B. Masi, “Access and Affordability: An Update for chronic obstructive pulmonary disease, but that coding on Health Reform in Massachusetts, Fall 2008,” Health Affairs changes were unlikely to have affected rates for other common Web Exclusive (May 28, 2009):w578–w587. conditions including diabetes, chronic heart failure, or bacterial pneumonia (personal communication with Ernest Moy, M.D., 7 “Income Eligibility Standards for Children’s Separate SCHIP Agency for Healthcare Research and Quality, Aug. 2009). Programs by Annual Incomes and as a Percent of Federal Poverty Level, 2009,” and “Income Eligibility Levels for Children’s 16E. A. Coleman, “Falling Through the Cracks: Challenges and Regular Medicaid and Children’s SCHIP-funded Medicaid Opportunities for Improving Transitional Care for Persons with Expansions by Annual Incomes and as Percent of Federal Continuous Complex Care Needs,” Journal of the American Poverty Level, 2009,” available from Kaiser Family Foundation Geriatrics Society, April 2003 51(4):549–55. statehealthfacts.org at http://www.statehealthfacts.org. 17 J. E. Wennberg, K. Bronner, J. S. Skinner et al., “Inpatient Care Accessed July 14, 2009. Intensity and Patients’ Ratings of Their Hospital Experiences,” 8 Kaiser Family Foundation Commission on Medicaid and the Health Affairs, Jan./Feb. 2009 28(1):103–12. Uninsured, “Expanding Health Coverage for Low-Income Adults: 18E.S. Fisher, D. E. Wennberg, T. A. Stukel et al., “The Implications Filling the Gaps in Medicaid Eligibility” (Menlo Park, Calif. Kaiser of Regional Variations in Medicare Spending, Part 2: Health Family Foundation, May 2009), available at http://www.kff. Outcomes and Satisfaction with Care,” Annals of Internal org/medicaid/upload/7900.pdf. Medicine, Feb. 2003 138(4):288–98. 9 M. V. Pauly and J. A. Pagan, “Spillovers and Vulnerability: The 19The nine chronic conditions are: malignant cancer/leukemia, Case of Community Uninsurance,” Health Affairs, Sept./Oct. 2007 chronic heart failure, chronic pulmonary disease, dementia, 26(5):1304–14. diabetes with end organ damage, peripheral vascular disease, 10B. Starfield and L. Shi, “The Medical Home, Access to Care, and chronic renal failure, severe chronic liver disease, and coronary Insurance: A Review of Evidence,” Pediatrics, May 2004 113(5 artery disease. Suppl):1493–98. 20Data were compiled by Kristen Bronner, managing editor, 11 The 2007 Medicare CAHPS survey had a smaller sample size than Dartmouth Atlas Project. in previous years and there was also a change in overall survey 21 E. S. Fisher, D. Goodman, J. S. Skinner et al., Health Care Spending, design. National data from the CAHPS Benchmarking Database Quality, and Outcomes: More Isn’t Always Better (Lebanon, N.H.: for 2008 indicate that ratings of provider communication Dartmouth Atlas of Health Care, Feb. 2009). (composite) held steady at 2007 levels while the overall rating of health care continued to decline. 22G. Claxton, B. DiJulio, B. Finder et al., Employer Health Benefits 2008 Annual Survey (Washington, D.C.: Kaiser Family Foundation and Health Research and Educational Trust, 2008). 67 23C. Schoen, J. L. Nicholson, and S. D. Rustgi, Paying the 34E. A. Finkelstein, J. G. Trogdon, J. W. Cohen et al., “Annual Price: How Health Insurance Premiums Are Eating Up Medical Spending Attributable to Obesity: Payer- and Service- Middle-Class Incomes—State Health Insurance Premium Specific Estimates,” Health Affairs Web Exclusive (July 27, Trends and the Potential of National Reform (New York: 2009):w822–w831. The Commonwealth Fund, Aug. 2009). 35Healthy People Objective 27-21a: to increase the combined 24G. M. Hackbarth, “Report to the Congress: Medicare Payment federal and average state cigarette tax to at least $2 per pack. Policy,” Testimony before the Subcommittee on Health, U.S. House of Representatives, March 17, 2009; J. M. Donnelly, 36Statement of Matthew L. Myers, president, Campaign for “Blue Cross Expands its Quality Contract Network,” Boston Tobacco-Free Kids, “Rhode Island Cigarette Tax Increase Delivers Business Journal, April 3, 2009, http://boston.bizjournals. Victory for Kids and Taxpayers; $1 Increase Give State Highest com/boston/stories/2009/04/06/story6.html; Blue Cross Cigarette Tax in the Nation,” April 10, 2009, available from Robert Blue Shield of Massachusetts, The Alternative Quality Contract, Wood Johnson Foundation News Releases at http://www.rwjf. http://www.qualityaffordability.com/pdf/alternative- org/pr/product.jsp?id=41491. Accessed Aug. 8, 2009. quality-contract.pdf. 37 L. Trasande, Y. Liu, G. Fryer et al., “Effects of Childhood Obesity 25Where there was more than one vulnerable subgroup (e.g., on Hospital Care and Costs, 1999–2005.” Health Affairs, July/Aug. multiple income or race/ethnicity categories), we selected the 2009 28(4):w751–w760. subgroup with the widest gap in comparison with the national 38G. Singh, M. D. Kogan, and P. C. van Dyck, “A Multilevel Analysis average in each state and in each time period. Hence, the “most of State and Regional Disparities in Childhood and Adolescent vulnerable” subgroup varies to some degree across states. Obesity in the United States,” Journal of Community Health, April 26Of the 11 indicators used in the equity analysis, the national 2008 33(4):90–102. average worsened for three, improved for four, did not change 39S. Silow-Carroll and T. Alteras, “Public Programs Are Using for one, and could not be compared over time for three indicators. Incentives to Promote Healthy Behavior,” States in Action 27The analysis of racial and ethnic disparities focuses on newsletter (New York: The Commonwealth Fund, Sept./ subgroups for which there were sufficient data in each state Oct. 2007). for valid comparisons. Sample sizes were too small to report 40H.R. 1256: Family Smoking Prevention and Tobacco Control Act. data separately for Asian American, Native American, and other subgroups whose experiences are combined in an 41C. L. Engelhard, A. Garson, Jr., and S. Dorn, Reducing Obesity: “other” category. Small states with relatively homogeneous Policy Strategies from the Tobacco Wars (Washington, D.C.: Urban populations (such as Maine, Vermont, and Wyoming) often Institute, July 2009); M. H. Katz, “Structural Interventions for had few subgroups for ranking. Addressing Chronic Health Problems,” Journal of the American Medical Association, Aug. 12, 2009 302(6):683–85. 28E. Nolte and C. M. McKee, “Measuring the Health of Nations: Updating an Earlier Analysis,” Health Affairs, Jan./Feb. 2008 42S. Silow-Carroll and T. Alteras, Value-Driven Health Care 27(1):58–71. Purchasing: Four States that Are Ahead of the Curve (New York: The Commonwealth Fund, Aug. 2007). 29Correlation between the state ranking on avoidable use and cost dimension and state rate of mortality amenable to health 43K. C. Allen, “Utah’s State Snapshots,” and F. Gesten, “AHRQ care is R2=0.56. State Snapshots: New York,” presentations for a Webinar on the Agency for Healthcare Research and Quality’s 2008 State 30D. Paul, A. Mackley, R. G. Locke et al., “State Infant Mortality: An Snapshots, July 9, 2009. Ecologic Study to Determine Modifiable Risks and Adjusted Infant Mortality Rates,” Maternal and Child Health Journal, June 44J. E. Fielding and S. M. Teutsch, “Integrating Clinical Care and 2009 13(3):343–48. Community Health: Delivering Health,” Journal of the American Medical Association, July 15, 2009 302(3):317–19. 31 T. Mark, D. Shern, J. E. Bagalman et al., Ranking America’s Mental Health: An Analysis of Depression Across the States (Alexandria, 45Schoen, Collins, Kriss, and Doty, “How Many Are Underinsured?” Va.: Mental Health America, Dec. 2007); L. Tondo, M. Albert, 2008. and R. J. Baldessarini, “Suicide Rates in Relation to Health Care 46Exhibit 33 shows the gain if all states were to achieve the rate Access in the United States: An Ecologic Study,” Journal of of the top state, based on state populations. Clinical Psychiatry, April 2006 67(4):517–23. 47S. Silow-Carroll and G. Moody, “Early Federal Action on Health 32P. S. Wang, O. Demler, and R. C. Kessler, “Adequacy of Treatment Policy: The Impact on States,” States in Action newsletter (New for Serious Mental Illness in the United States,” American York: The Commonwealth Fund, Feb./March 2009). Journal of Public Health, Jan. 2002 92(1):92–98; “Mental Health Care: Adequacy of Treatment for Adults,” available from 48M. Davis, “S-CHIP Expansion Keeps 12,500 RI Kids Covered,” Commonwealth Fund Performance Snapshots at http:// Providence Business News, Feb. 9, 2009, available at http:// www.commonwealthfund.org/Content/Performance- www.pbn.com/detail/40112.html. Snapshots/Mental-and-Behavioral-Health-Care/Mental- 49For a summary of Massachusetts reform law and its effects, see: Health-Care--Adequacy-of-Treatment-for-Adults.aspx. G. Moody, “Massachusetts: Sharing Responsibility to Achieve Accessed July 13, 2009. Near-Universal Access,” States in Action newsletter (New York: 33Centers for Disease Control and Prevention, “Smoking- The Commonwealth Fund, forthcoming). Attributable Mortality, Years of Potential Life Lost, and 50Massachusetts Health Connector Authority, “Health Reform Productivity Losses, United States, 2000–2004,” Morbidity and Facts and Figures,” June 2009, available at http://www. Mortality Weekly Report, Nov. 14, 2008 57(45):1226–28. mahealthconnector.org. 68 51 D. Montaño, “New BadgerCare Health Coverage Plan Targets 67Minnesota Health Information Exchange Web site, http://www. Childless Adults,” Milwaukee Wisconsin Journal Sentinel, June mnhie.org. Accessed July 13, 2009. 17, 2009, available at http://www.jsonline.com/news/ wisconsin/48298447.html. 68“Arizona’s Statewide HIE Utility,” Sept. 15, 2008, available from Commonwealth Fund Web site at h t t p : / / w w w. 52Health Care for All Oregon Web site: h t t p : / / w w w. commonwealthfund.org/Content/Innovations/State- healthcareforalloregon.org. Profiles/2008/Sep/Arizonas-Statewide-HIE-Utility.aspx. Accessed July 13, 2009; A. D. Rodgers, presentation at the 53Commonwealth Fund Commission, Path to High Performance, Commonwealth Fund State Quality Improvement Institute, 2009; K. Davis, C, Schoen, S. Guterman, and K. Stremikis, Fork Denver, Colo., May 27, 2009. in the Road: Alternative Paths to a High Performance U.S. Health System (New York: The Commonwealth Fund, June 2009); S. 69“Indiana’s Health Information Exchange: Congressional Leaders Guterman, K. Davis, C. Schoen, and K. Stremikis, Reforming Can Look to Indiana for Innovative Approach to Health IT in Provider Payment: Essential Building Block for Health Reform Economic Stimulus Package,” Feb. 13, 2009, available from (New York: The Commonwealth Fund, March 2009). Government Innovators Network Web site at http://www. innovations.harvard.edu/news/151781.html. Accessed 54K. Kuhmerker and T. Hartman, Pay-for-Performance in State July 13, 2009. Medicaid Programs: A Survey of State Medicaid Directors and Programs (New York: The Commonwealth Fund, April 2007). 70State of Alabama, E-Prescribing Capability Added to QTool Electronic Health Record (Montgomery: Alabama Medicaid 55Silow-Carroll and Moody, “Early Federal Action”, 2009. Agency Web site, http://www.medicaid.alabama.gov/ 56Commonwealth of Massachusetts, Recommendations of the documents/News/MM_E-Prescribe_4-22-09.pdf. Accessed Special Commission on the Health Care Payment System, July Aug. 7, 2009. 16, 2009, http://www.mass.gov/Eeohhs2/docs/dhcfp/pc/ 71 J. Rosenthal and C. Hanlon, State Partnerships to Improve Quality: Final_Report/Final_Report.pdf. Models and Practices from Leading States (Portland, Maine: 57M. K. Abrams, “Achieving Person-Centered Primary Care: The National Academy for State Health Policy, June 2009). Patient-Centered Medical Home,” Invited Testimony, Special 72K. C. Allen, “Utah State Case Study,” presentation to the Agency Senate Committee on Aging, hearing on “Person-Centered for Healthcare Research and Quality’s State Healthcare Quality Care: Reforming Services and Bringing Older Citizens Back to Improvement Workshop, Phoenix, Ariz.: Jan. 17–18, 2008, http:// the Heart of Society,” July 23, 2008. www.academyhealth.org/ahrq/qualitytools/agenda_ 58Minnesota Medical Association, “Health Care Reform: The Road phoenix.htm. Ahead,” (special supplement to Minnesota Medicine Sept. 2008), 73S. Silow-Carroll and G. Moody, “Feature: Public Health in the available at http://www.MMAonline.net. State Reform Spotlight,” States in Action newsletter (New York: 59S. Silow-Carroll and G. Moody, “The State Quality Improvement The Commonwealth Fund, June/July 2009). Institute,” States in Action (New York: The Commonwealth Fund, 74Rosenthal and Hanlon, State Partnerships, 2009. Aug./Sept. 2008). 75Ibid. 60S. Silow-Carroll and G. Moody, “Massachusetts Action Plan,” States in Action (New York: The Commonwealth Fund, Aug./ 76S. Silow-Carroll, J. Bitterman, and G. Moody, “North Carolina Sept. 2008). Healthcare Quality Alliance,” States in Action newsletter (New York: The Commonwealth Fund, June/July 2008). 61S. Silow-Carroll and G. Moody, “Vermont: Community Care Teams and Health IT,” States in Action (New York: The 77 McCarthy and Mueller, Community Care of North Carolina, 2009. Commonwealth Fund, June/July 2009). 78K. Davis, “Changing Course: Trends in Health Insurance 62D. McCarthy and K. Mueller, Community Care of North Carolina: Coverage, 2000–2008,” Invited Testimony, Joint Economic Building Community Systems of Care Through State and Local Committee, hearing on “Income, Poverty, and Health Insurance Partnerships (New York: The Commonwealth Fund, June 2009). Coverage: Assessing Key Consensus Indicators of Family Well- Being in 2008,” Sept. 10, 2009. 63M. Takach, The Role of FQHCs in State-Led Multi-Payer Medical Home Collaboratives (Portland, Maine: National Academy for State Health Policy, June 2009). 64“Children’s Coverage and SCHIP Reauthorization,” available from Kaiser Family Foundation Issue Module at http://www. kaiseredu.org/topics_im.asp?id=704&imID=1&parent ID=65. Accessed July 13, 2009; American Medical Association, “Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Summary of Key Provisions,” available at http:// www.ama-assn.org/ama1/pub/upload/mm/399/schip- chipra-hr2-summary.pdf. 65C. Schoen, S. Guterman, A. Shih, J. Lau, S. Kasimow, A. Gauthier, and K. Davis, Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending (New York: The Commonwealth Fund, Dec. 2007). 66Silow-Carroll and Moody, “Early Federal Action,” 2009. 69 A ppendices Appendix A E x hibit A 1 Summary of Indicator Rankings by State E x hibit A 2 Summary of State Median Rates and Range of State Performance Across Indicators with Trends E x hibit A 3 Summary of Performance Across Indicators with Trends by State E x hibit A 4 Summary of Improvement in Closing Equity Gaps by State E x hibit A 5 Access: Dimension and Indicator Ranking E x hibit A 6 Access: Dimension Ranking and Performance on Indicators E x hibit A 7 Uninsured Rates and Medicaid/CHIP Eligibility Standards by State E x hibit A 8 Prevention and Treatment: Dimension and Indicator Ranking on Effective Care, Coordinated Care, and Patient-Centered Care E x hibit A 9 Prevention and Treatment: Dimension Ranking and Performance on Indicators E x hibit A 1 0 Hospital Quality Indicator Composite Percent and Rank: Hospitalized Patients Who Received Recommended Care for Heart Attack, Heart Failure, and Pneumonia E x hibit A 1 1 Avoidable Hospital Use and Costs: Dimension and Indicator Ranking E x hibit A 1 2 Avoidable Hospital Use and Costs: Dimension Ranking and Performance on Indicators E x hibit A 1 3 Healthy Lives: Dimension and Indicator Ranking E x hibit A 1 4 Healthy Lives: Dimension Ranking and Performance on Indicators E x hibit A 1 5 Mortality Amenable to Health Care by Race E x hibit A 1 6 State Demographics: Income and Health Status E x hibit A 1 7 State Demographics: Race and Ethnic Groups A ppendix B ppendi x B . 1 A State Scorecard Data Years and Databases ppendi x B . 2 A State Scorecard Indicator Descriptions ppendi x B . 3 A Complete References for Data Sources 70 ExHIBIT A1 Summary of Indicator Rankings by State overall no. of main Top 5 Top 2nd 3rd Bottom Bottom 5 rank* state indicators states Quartile Quartile Quartile Quartile states 40 Alabama 36 0 0% 5 14% 7 19% 11 31% 13 36% 4 11% 34 Alaska 35 3 9% 9 26% 5 14% 6 17% 15 43% 6 17% 36 Arizona 38 1 3% 4 11% 13 34% 8 21% 13 34% 4 11% 48 Arkansas 37 1 3% 2 5% 8 22% 7 19% 20 54% 9 24% 31 California 38 1 3% 5 13% 14 37% 8 21% 11 29% 4 11% 24 Colorado 37 2 5% 9 24% 13 35% 11 30% 4 11% 1 3% 8 Connecticut 38 7 18% 17 45% 11 29% 6 16% 4 11% 0 0% 14 Delaware 37 8 22% 13 35% 9 24% 7 19% 8 22% 1 3% 26 District of Columbia 35 7 20% 10 29% 7 20% 4 11% 14 40% 11 31% 44 Florida 37 0 0% 4 11% 8 22% 13 35% 12 32% 4 11% 38 Georgia 38 1 3% 2 5% 11 29% 12 32% 13 34% 3 8% 2 Hawaii 36 14 39% 22 61% 6 17% 4 11% 4 11% 3 8% 29 Idaho 37 6 16% 17 46% 2 5% 9 24% 9 24% 5 14% 42 Illinois 34 0 0% 3 9% 8 24% 8 24% 15 44% 1 3% 28 Indiana 38 0 0% 2 5% 16 42% 14 37% 6 16% 1 3% 2 Iowa 38 11 29% 21 55% 11 29% 4 11% 2 5% 1 3% 23 Kansas 36 1 3% 5 14% 14 39% 15 42% 2 6% 0 0% 45 Kentucky 38 1 3% 2 5% 5 13% 17 45% 14 37% 8 21% 49 Louisiana 37 1 3% 5 14% 1 3% 4 11% 27 73% 17 46% 5 Maine 36 4 11% 22 61% 8 22% 3 8% 3 8% 1 3% 17 Maryland 37 3 8% 8 22% 13 35% 10 27% 6 16% 2 5% 7 Massachusetts 37 11 30% 14 38% 16 43% 3 8% 4 11% 1 3% 20 Michigan 38 1 3% 5 13% 12 32% 16 42% 5 13% 1 3% 4 Minnesota 38 11 29% 25 66% 8 21% 4 11% 1 3% 1 3% 51 Mississippi 37 0 0% 3 8% 1 3% 7 19% 26 70% 14 38% 36 Missouri 38 0 0% 3 8% 8 21% 18 47% 9 24% 2 5% 18 Montana 37 4 11% 11 30% 14 38% 4 11% 8 22% 4 11% 13 Nebraska 36 6 17% 19 53% 6 17% 11 31% 0 0% 0 0% 47 Nevada 37 1 3% 3 8% 4 11% 6 16% 24 65% 12 32% 5 New Hampshire 38 10 26% 20 53% 11 29% 5 13% 2 5% 1 3% 30 New Jersey 38 3 8% 11 29% 6 16% 9 24% 12 32% 5 13% 42 New Mexico 37 0 0% 9 24% 6 16% 6 16% 16 43% 8 22% 21 New York 38 1 3% 5 13% 13 34% 12 32% 8 21% 6 16% 41 North Carolina 38 0 0% 2 5% 14 37% 16 42% 6 16% 1 3% 9 North Dakota 36 10 28% 21 58% 5 14% 7 19% 3 8% 2 6% 27 Ohio 38 1 3% 4 11% 9 24% 15 39% 10 26% 1 3% 50 Oklahoma 37 0 0% 1 3% 4 11% 8 22% 24 65% 10 27% 32 Oregon 37 8 22% 14 38% 4 11% 5 14% 14 38% 7 19% 15 Pennsylvania 37 2 5% 7 19% 16 43% 11 30% 3 8% 0 0% 11 Rhode Island 37 7 19% 13 35% 11 30% 9 24% 4 11% 2 5% 33 South Carolina 37 2 5% 4 11% 11 30% 13 35% 9 24% 2 5% 12 South Dakota 37 8 22% 17 46% 9 24% 8 22% 3 8% 0 0% 39 Tennessee 37 2 5% 3 8% 8 22% 13 35% 13 35% 2 5% 46 Texas 38 0 0% 1 3% 9 24% 12 32% 16 42% 6 16% 19 Utah 38 13 34% 16 42% 8 21% 6 16% 8 21% 4 11% 1 Vermont 38 8 21% 22 58% 10 26% 5 13% 1 3% 1 3% 22 Virginia 37 0 0% 3 8% 23 62% 8 22% 3 8% 0 0% 16 Washington 38 6 16% 14 37% 9 24% 9 24% 6 16% 3 8% 35 West Virginia 37 1 3% 5 14% 5 14% 14 38% 13 35% 6 16% 10 Wisconsin 38 5 13% 15 39% 17 45% 4 11% 2 5% 0 0% 25 Wyoming 36 5 14% 10 28% 8 22% 8 22% 10 28% 5 14% * Final rank for overall health system performance across five dimensions SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 71 ExHIBIT A2 Summary of State Median Rates and Range of State Performance Across Indicators with Trends Prevention Avoidable Total Access & Treatment Use & Costs Healthy Lives Count Percent Count Percent Count Percent Count Percent Count Percent Total indicators with trends* 35 100% 4 100% 14 100% 9 100% 8 100% All States Median Improved by 5% or more 15 43% 0 0% 9 64% 2 22% 4 50% Worsened by 5% or more 7 20% 0 0% 1 7% 5 56% 1 13% No change or less than 5% change 13 37% 4 100% 4 29% 2 22% 3 38% Top 5 States Average Rate Improved by 5% or more 13 37% 0 0% 7 50% 2 22% 4 50% Worsened by 5% or more 7 20% 0 0% 1 7% 4 44% 2 25% No change or less than 5% change 15 43% 4 100% 6 43% 3 33% 2 25% Bottom 5 States Average Rate Improved by 5% or more 15 43% 0 0% 10 71% 2 22% 3 38% Worsened by 5% or more 6 17% 1 25% 1 7% 2 22% 2 25% No change or less than 5% change 14 40% 3 75% 3 21% 5 56% 3 38% Range of Peformance (Bottom 5 – Top 5 States) Narrowed by 5% or more 13 37% 0 0% 8 57% 3 33% 2 25% Widened by 5% or more 11 31% 3 75% 3 21% 4 44% 1 13% No change or less than 5% change 11 31% 1 25% 3 21% 2 22% 5 63% * Three indicators are excluded because data do not allow assessment of trends. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 72 ExHIBIT A3 Summary of Performance Across Indicators With Trends by State Total State Rate Improved State Rate Worsened No Change or Less than 5% indicators by 5% or more by 5% or more Change in State Rate state with trends Count Percent Count Percent Count Percent Alabama 34 12 35% 7 21% 15 44% Alaska 32 13 41% 7 22% 12 38% Arizona 35 15 43% 7 20% 13 37% Arkansas 34 17 50% 8 24% 9 26% California 35 15 43% 7 20% 13 37% Colorado 35 16 46% 10 29% 9 26% Connecticut 34 15 44% 9 26% 10 29% Delaware 34 17 50% 7 21% 10 29% District of Columbia 31 17 55% 8 26% 6 19% Florida 35 15 43% 6 17% 14 40% Georgia 35 15 43% 8 23% 12 34% Hawaii 33 15 45% 10 30% 8 24% Idaho 34 12 35% 6 18% 16 47% Illinois 32 13 41% 11 34% 8 25% Indiana 34 14 41% 8 24% 12 35% Iowa 35 14 40% 7 20% 14 40% Kansas 34 13 38% 7 21% 14 41% Kentucky 35 17 49% 6 17% 12 34% Louisiana 34 13 38% 5 15% 16 47% Maine 34 13 38% 8 24% 13 38% Maryland 34 16 47% 7 21% 11 32% Massachusetts 34 14 41% 9 26% 11 32% Michigan 34 13 38% 11 32% 10 29% Minnesota 35 15 43% 7 20% 13 37% Mississippi 34 13 38% 8 24% 13 38% Missouri 35 15 43% 9 26% 11 31% Montana 34 11 32% 11 32% 12 35% Nebraska 34 12 35% 9 26% 13 38% Nevada 35 15 43% 7 20% 13 37% New Hampshire 35 12 34% 10 29% 13 37% New Jersey 35 17 49% 6 17% 12 34% New Mexico 34 9 26% 11 32% 14 41% New York 35 15 43% 7 20% 13 37% North Carolina 35 14 40% 10 29% 11 31% North Dakota 34 14 41% 6 18% 14 41% Ohio 35 17 49% 10 29% 8 23% Oklahoma 34 11 32% 8 24% 15 44% Oregon 34 15 44% 9 26% 10 29% Pennsylvania 34 15 44% 4 12% 15 44% Rhode Island 34 16 47% 9 26% 9 26% South Carolina 35 14 40% 8 23% 13 37% South Dakota 34 13 38% 6 18% 15 44% Tennessee 35 13 37% 7 20% 15 43% Texas 35 14 40% 5 14% 16 46% Utah 35 17 49% 8 23% 10 29% Vermont 35 14 40% 7 20% 14 40% Virginia 34 14 41% 7 21% 13 38% Washington 35 14 40% 10 29% 11 31% West Virginia 35 18 51% 6 17% 11 31% Wisconsin 35 14 40% 7 20% 14 40% Wyoming 34 11 32% 9 26% 14 41% SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 73 ExHIBIT A4 Summary of Improvement in Closing Equity Gaps by State Overall Income Insurance Coverage Race/Ethnicity Gap Narrowed and Gap Narrowed and Gap Narrowed and Gap Narrowed and Total equity Vulnerable Group Low-Income Group Uninsured Group Non-White Group indicators Improved Improved Improved Improved State with trends Count Percent Count Percent Count Percent Count Percent Alabama 17 8 47% 2 33% 1 25% 5 71% Alaska 17 5 29% 1 17% 1 25% 3 43% Arizona 17 3 18% 0 0% 1 25% 2 29% Arkansas 17 3 18% 0 0% 0 0% 3 43% California 17 6 35% 3 50% 0 0% 3 43% Colorado 17 3 18% 1 17% 1 25% 1 14% Connecticut 17 10 59% 3 50% 3 75% 4 57% Delaware 17 10 59% 3 50% 1 25% 6 86% District of Columbia 16 6 38% 2 40% 1 25% 3 43% Florida 17 3 18% 0 0% 1 25% 2 29% Georgia 17 8 47% 3 50% 2 50% 3 43% Hawaii 17 6 35% 2 33% 1 25% 3 43% Idaho 16 3 19% 0 0% 0 0% 3 50% Illinois 16 4 25% 1 20% 0 0% 3 43% Indiana 17 7 41% 4 67% 2 50% 1 14% Iowa 16 6 38% 1 17% 1 25% 4 67% Kansas 16 5 31% 2 40% 1 25% 2 29% Kentucky 17 2 12% 0 0% 0 0% 2 29% Louisiana 17 1 6% 1 17% 0 0% 0 0% Maine 13 6 46% 4 67% 1 25% 1 33% Maryland 16 6 38% 1 20% 3 75% 2 29% Massachusetts 16 7 44% 3 60% 0 0% 4 57% Michigan 16 8 50% 2 40% 2 50% 4 57% Minnesota 16 7 44% 1 17% 2 50% 4 67% Mississippi 17 6 35% 2 33% 2 50% 2 29% Missouri 17 3 18% 0 0% 0 0% 3 43% Montana 15 8 53% 2 33% 1 25% 5 100% Nebraska 16 3 19% 0 0% 2 50% 1 14% Nevada 17 8 47% 3 50% 0 0% 5 71% New Hampshire 13 5 38% 1 17% 1 25% 3 100% New Jersey 17 4 24% 0 0% 1 25% 3 43% New Mexico 17 2 12% 0 0% 0 0% 2 29% New York 17 10 59% 3 50% 3 75% 4 57% North Carolina 17 2 12% 0 0% 0 0% 2 29% North Dakota 14 5 36% 1 17% 2 50% 2 50% Ohio 17 5 29% 2 33% 2 50% 1 14% Oklahoma 17 8 47% 3 50% 2 50% 3 43% Oregon 16 9 56% 2 40% 2 50% 5 71% Pennsylvania 17 7 41% 2 33% 2 50% 3 43% Rhode Island 16 7 44% 2 40% 2 50% 3 43% South Carolina 17 6 35% 2 33% 2 50% 2 29% South Dakota 15 3 20% 1 17% 2 50% 0 0% Tennessee 17 8 47% 1 17% 2 50% 5 71% Texas 17 8 47% 4 67% 2 50% 2 29% Utah 17 9 53% 4 67% 1 25% 4 57% Vermont 13 4 31% 2 33% 1 25% 1 33% Virginia 17 4 24% 1 17% 1 25% 2 29% Washington 17 7 41% 1 17% 1 25% 5 71% West Virginia 16 7 44% 4 67% 1 25% 2 33% Wisconsin 17 10 59% 4 67% 3 75% 3 43% Wyoming 13 2 15% 1 20% 0 0% 1 25% SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 74 EXHIBIT A5 Access: Dimension and Indicator Ranking State Rank Top Quartile p up u ck ck Second Quartile he he Third Quartile eC eC t in t in Bottom Quartile ou ou os r os r f C c to f C c to rR rR en en t t eo o eo o lts lts t fo t fo dr dr us e D us e D 2009 Ranking Revised 2007 Rankinga du du hil hil isi isi ca Se ca Se dA dA dC dC rV rV Be Not Be Not ure ure ure ure c to c to d d Ins Ins Ins Ins Do Do Di Di RANK S TAT E RANK S TAT E 1 Massachusetts 1 Hawaii 2 Minnesota 2 Massachusetts 3 Connecticut 3 Rhode Island 4 Iowa 4 Iowa 5 Maine 5 Connecticut 6 Hawaii 5 Minnesota 7 District of Columbia 7 New Hampshire 8 New Hampshire 8 Maine 9 Wisconsin 9 District of Columbia 10 Delaware 10 Michigan 11 Rhode Island 11 Pennsylvania 12 Pennsylvania 12 Vermont 13 Michigan 13 Wisconsin 13 Vermont 13 Nebraska 15 North Dakota 15 North Dakota 16 Maryland 15 Kansas 17 South Dakota 17 Ohio 18 New York 18 New York 19 Ohio 19 Delaware 20 Illinois 20 Maryland 21 Alabama 21 Missouri 22 Virginia 22 South Dakota 23 Washington 23 Illinois 24 Indiana 24 New Jersey 25 Kansas 25 Virginia 25 Nebraska 26 Tennessee 27 West Virginia 27 Washington 27 New Jersey 28 Alabama 29 Tennessee 29 Kentucky 30 Missouri 30 Arizona 31 Utah 31 South Carolina 32 Wyoming 32 North Carolina 32 North Carolina 33 Indiana 34 Kentucky 34 Louisiana 35 Montana 35 West Virginia 36 Georgia 36 Colorado 37 Louisiana 36 Alaska 37 Arizona 38 Wyoming 39 South Carolina 39 Florida 40 Colorado 39 Arkansas 41 California 41 Utah 42 Oregon 42 Idaho 42 Florida 43 Georgia 44 Arkansas 44 Montana 45 Idaho 45 Nevada 46 Nevada 46 Oregon 47 Oklahoma 47 Oklahoma 48 Alaska 48 California 49 Mississippi 49 Mississippi 50 New Mexico 50 New Mexico 51 Texas 51 Texas a Some state rates from the 2007 edition have been revised to match methodology used in the 2009 edition. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 75 ExHIBIT A6 Access: Dimension Ranking and Performance on Indicators Note: Change in rate is expressed such that a positive value indicates performance has improved and a negative value indicates Indicator Performance performance has worsened. Percent Nonelderly Adults Percent Children (Ages 18–64) Insured (Ages 0–17) Insured Current Past Actual Percent Actual Percent Dimension Dimension Change in Change in Change in Change in State Rank Rank Current Rate Ratea Ratea Current Rate Rate a Ratea United States 80.0 -0.4 -0.5% 89.6 0.3 0.3% Alabama 21 28 83.0 2.1 2.6% 94.5 -0.1 -0.1% Alaska 48 36 75.9 -1.8 -2.3% 87.1 -3.8 -4.2% Arizona 37 30 76.4 -0.4 -0.5% 85.1 0.3 0.4% Arkansas 44 39 76.0 -0.1 -0.1% 92.3 0.8 0.9% California 41 48 75.6 -0.7 -0.9% 89.4 2.0 2.3% Colorado 40 36 80.3 -0.4 -0.5% 87.3 1.4 1.6% Connecticut 3 5 86.7 1.2 1.4% 94.7 2.1 2.3% Delaware 10 19 85.7 1.3 1.5% 91.7 3.4 3.9% District of Columbia 7 9 88.0 4.3 5.1% 93.8 0.6 0.6% Florida 42 39 74.1 0.3 0.4% 82.0 -1.8 -2.1% Georgia 36 43 77.2 -0.1 -0.1% 89.0 0.2 0.2% Hawaii 6 1 89.4 1.3 1.5% 94.9 -0.5 -0.5% Idaho 45 42 79.9 -1.1 -1.4% 90.1 0.1 0.1% Illinois 20 23 82.2 -0.8 -1.0% 93.5 3.8 4.2% Indiana 24 33 83.4 1.1 1.3% 94.4 3.5 3.9% Iowa 4 4 87.2 -1.2 -1.4% 95.0 0.5 0.5% Kansas 25 15 83.9 -1.8 -2.1% 90.6 -3.1 -3.3% Kentucky 34 29 80.1 -2.2 -2.7% 91.0 -1.5 -1.6% Louisiana 37 34 73.8 -2.0 -2.6% 88.1 -4.2 -4.6% Maine 5 8 86.7 -0.6 -0.7% 94.6 0.7 0.7% Maryland 16 20 83.2 0.6 0.7% 91.7 0.5 0.5% Massachusetts 1 2 92.8 6.7 7.8% 96.8 1.8 1.9% Michigan 13 10 83.9 -1.3 -1.5% 94.5 0.0 0.0% Minnesota 2 5 89.2 -0.4 -0.4% 93.5 -0.4 -0.4% Mississippi 49 49 75.8 -2.2 -2.8% 87.3 -0.4 -0.5% Missouri 30 21 83.4 -0.8 -1.0% 91.4 -1.2 -1.3% Montana 35 44 78.9 0.6 0.8% 88.4 2.4 2.8% Nebraska 25 13 84.2 -1.4 -1.6% 90.0 -4.4 -4.7% Nevada 46 45 78.4 0.3 0.4% 83.3 -1.6 -1.9% New Hampshire 8 7 86.1 -0.7 -0.8% 95.0 0.8 0.8% New Jersey 27 24 81.2 -0.7 -0.9% 87.9 -1.8 -2.0% New Mexico 50 50 69.8 -4.9 -6.6% 84.2 1.5 1.8% New York 18 18 82.0 -0.7 -0.8% 92.0 -0.8 -0.9% North Carolina 32 32 78.9 -1.4 -1.7% 89.3 0.2 0.2% North Dakota 15 15 85.7 -0.9 -1.0% 92.1 1.1 1.2% Ohio 19 17 84.5 -1.2 -1.4% 92.8 0.6 0.7% Oklahoma 47 47 78.0 2.9 3.9% 90.1 3.6 4.2% Oregon 42 46 78.4 -0.4 -0.5% 88.9 -0.7 -0.8% Pennsylvania 12 11 87.1 0.4 0.5% 92.9 1.4 1.5% Rhode Island 11 3 85.6 -0.2 -0.2% 91.6 -1.0 -1.1% South Carolina 39 31 79.4 1.4 1.8% 86.5 -4.5 -4.9% South Dakota 17 22 84.9 0.2 0.2% 91.1 -0.9 -1.0% Tennessee 29 26 79.9 -2.4 -2.9% 90.7 -0.1 -0.1% Texas 51 51 68.5 -1.9 -2.7% 80.4 0.2 0.2% Utah 31 41 83.8 2.2 2.7% 90.0 1.3 1.5% Vermont 13 12 86.5 1.5 1.8% 93.4 -1.6 -1.7% Virginia 22 25 82.1 -0.7 -0.8% 91.5 -0.6 -0.7% Washington 23 27 84.3 1.4 1.7% 93.2 0.9 1.0% West Virginia 27 35 78.9 2.3 3.0% 94.6 2.3 2.5% Wisconsin 9 13 88.1 1.2 1.4% 94.2 0.0 0.0% Wyoming 32 38 81.8 -0.6 -0.7% 90.8 0.6 0.7% 5% change 5% change Any change or more Any change or more Number of states with trends: 51 51 51 51 Rate improved (+) 20 2 28 0 Rate worsened (-) 31 1 21 0 Little/no change in rate 0 48 2 51 a A positive or negative value indicates that current performance is better or worse. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 76 E x H I B I T A 6 (continued) Access: Dimension Ranking and Performance on Indicators (continued) Note: Change in rate is expressed such that a positive value indicates performance has improved Indicator Performance and a negative value indicates Percent At-Risk Adults Visited Doctor Percent Adults Without Time When performance has worsened. for Routine Checkup in Past Two Years Could Not See Doctor Because of Cost Actual Percent Actual Percent Change in Change in Change in Change in State Current Rate Ratea Ratea Current Rate Rate a Ratea United States 84.6 -2.4 -2.8% 86.6 -0.3 -0.3% Alabama 86.6 1.5 1.8% 83.7 -1.1 -1.3% Alaska 77.6 -5.6 -6.7% 85.6 -1.6 -1.8% Arizona 84.5 -5.6 -6.2% 86.8 -1.0 -1.1% Arkansas 79.1 -6.7 -7.8% 83.0 -0.8 -1.0% California 82.2 1.6 2.0% 86.2 -1.1 -1.3% Colorado 78.9 -6.6 -7.7% 87.1 -0.5 -0.6% Connecticut 88.0 -3.6 -3.9% 90.9 0.1 0.1% Delaware 91.8 0.6 0.7% 90.7 -0.2 -0.2% District of Columbia 90.9 -2.6 -2.8% 90.1 1.4 1.6% Florida 87.5 -2.5 -2.8% 84.9 -0.4 -0.5% Georgia 85.5 0.0 0.0% 84.6 0.3 0.4% Hawaii 84.0 -6.3 -7.0% 93.1 -0.6 -0.6% Idaho 76.1 -2.9 -3.7% 84.2 -1.0 -1.2% Illinois 84.1 -5.1 -5.7% 87.5 -1.2 -1.4% Indiana 81.7 -1.3 -1.6% 86.5 -0.5 -0.6% Iowa 85.6 -0.6 -0.7% 92.2 0.4 0.4% Kansas 83.1 -4.3 -4.9% 89.3 1.0 1.1% Kentucky 83.3 -2.4 -2.8% 82.5 0.3 0.4% Louisiana 88.7 0.6 0.7% 82.5 -0.1 -0.1% Maine 88.0 -0.5 -0.6% 90.7 1.3 1.5% Maryland 88.1 -3.6 -3.9% 89.5 1.2 1.4% Massachusetts 91.3 -1.8 -1.9% 92.7 0.1 0.1% Michigan 86.0 -3.2 -3.6% 88.0 -0.5 -0.6% Minnesota 88.7 0.9 1.0% 90.9 0.2 0.2% Mississippi 82.1 -1.6 -1.9% 81.3 0.5 0.6% Missouri 80.4 -6.4 -7.4% 85.9 -2.4 -2.7% Montana 80.0 -2.4 -2.9% 88.0 1.0 1.1% Nebraska 81.0 -4.6 -5.4% 90.7 0.3 0.3% Nevada 77.6 -6.6 -7.8% 85.9 0.0 0.0% New Hampshire 88.0 -1.2 -1.3% 90.3 0.3 0.3% New Jersey 88.3 -3.1 -3.4% 88.0 0.3 0.3% New Mexico 80.1 -3.6 -4.3% 84.8 -0.8 -0.9% New York 87.2 -4.0 -4.4% 88.7 1.5 1.7% North Carolina 85.8 -3.6 -4.0% 83.5 -0.6 -0.7% North Dakota 81.1 -5.4 -6.2% 92.7 -0.5 -0.5% Ohio 83.9 -4.1 -4.7% 87.3 -2.2 -2.5% Oklahoma 75.0 -12.0 -13.8% 82.6 -0.1 -0.1% Oregon 80.2 -2.6 -3.1% 86.5 3.1 3.7% Pennsylvania 86.4 -3.5 -3.9% 90.1 0.0 0.0% Rhode Island 93.0 -1.2 -1.3% 90.4 -0.3 -0.3% South Carolina 83.4 -5.4 -6.1% 85.1 0.5 0.6% South Dakota 83.1 -2.2 -2.6% 91.0 -0.1 -0.1% Tennessee 90.5 0.8 0.9% 84.4 -2.7 -3.1% Texas 81.6 -1.1 -1.3% 80.7 -0.1 -0.1% Utah 76.8 -4.9 -6.0% 87.9 0.8 0.9% Vermont 84.4 -2.8 -3.2% 89.9 0.0 0.0% Virginia 84.7 -2.0 -2.3% 89.0 0.8 0.9% Washington 80.9 -4.9 -5.7% 87.6 1.2 1.4% West Virginia 87.7 0.3 0.3% 82.8 1.4 1.7% Wisconsin 84.8 2.9 3.5% 91.5 -0.1 -0.1% Wyoming 75.3 -5.5 -6.8% 87.2 0.3 0.3% 5% change 5% change Any change or more Any change or more Number of states with trends: 51 51 51 51 Rate improved (+) 8 0 23 0 Rate worsened (-) 42 15 25 0 Little/no change in rate 1 36 3 51 a A positive or negative value indicates that current performance is better or worse. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 77 ExHIBIT A7 Uninsured Rates and Medicaid/CHIP Income Eligibility Standards by State Income Eligibility for Medicaid/CHIP Percent Uninsured, 2007–08 (Percent of federal poverty levels), 2009 Children Adults (under age 18) (ages 18–64) Children Parents Childless Adults Alabama 5.5% 17.0% 200 25 NA Alaska 12.9% 24.1% 175 85 NA Arizona 14.9% 23.6% 200 200 100 Arkansas 7.7% 24.0% 200 17 NA California 10.6% 24.4% 250 106 NA Colorado 12.7% 19.7% 205 66 NA Connecticut 5.3% 13.3% 300 191/300* 300* Delaware 8.3% 14.3% 200 121 100 District of Columbia 6.2% 12.0% 300 207 200* Florida 18.0% 25.9% 200 55 NA Georgia 11.0% 22.8% 235 52 NA Hawaii 5.1% 10.6% 300 100/200* 100^/200* Idaho 9.9% 20.1% 185 28 NA Illinois 6.5% 17.8% 200 185 NA Indiana 5.6% 16.6% 250 26/200* 200*^ Iowa 5.0% 12.8% 200 86/200* 200* Kansas 9.4% 16.1% 200 34 NA Kentucky 9.0% 19.9% 200 62 NA Louisiana 11.9% 26.2% 250 26 NA Maine 5.4% 13.3% 200 206/300* 100*^/300* Maryland 8.3% 16.8% 300 116 116* Massachusetts 3.2% 7.2% 300 133/300* 133/300* Michigan 5.5% 16.1% 200 66 35* Minnesota 6.5% 10.8% 275 200/275* 200* Mississippi 12.7% 24.2% 200 46 NA Missouri 8.6% 16.6% 300 26 NA Montana 11.6% 21.1% 175 58 NA Nebraska 10.0% 15.8% 185 58 NA Nevada 16.7% 21.6% 200 91 NA New Hampshire 5.0% 13.9% 300 51 NA New Jersey 12.1% 18.8% 350 200 NA New Mexico 15.8% 30.2% 235 69/200* 200* New York 8.0% 18.0% 250 150 100 North Carolina 10.7% 21.1% 200 51 NA North Dakota 7.9% 14.3% 150 62 NA Ohio 7.2% 15.5% 200 90 NA Oklahoma 9.9% 22.0% 185 48/200* 200* Oregon 11.1% 21.6% 185 42/100*^/185*^ 100*^/185*^ Pennsylvania 7.1% 12.9% 300 36/200*^ 200*^ Rhode Island 8.4% 14.4% 250 181 NA South Carolina 13.5% 20.6% 200 90 NA South Dakota 8.9% 15.1% 200 54 NA Tennessee 9.3% 20.1% 250 134 NA Texas 19.6% 31.5% 200 27 NA Utah 10.0% 16.2% 200 68/150* 150* Vermont 6.6% 13.5% 300 191/300* 150/300* Virginia 8.5% 17.9% 200 30 NA Washington 6.8% 15.7% 250 77/200*^ 200*^ West Virginia 5.4% 21.1% 220 34 NA Wisconsin 5.8% 11.9% 250 200 200* Wyoming 9.2% 18.2% 200 54 NA * Denotes income eligibility for a waiver or state-funded program with more limited benefits and/or higher cost-sharing than Medicaid. ^Denotes enrollment is closed to new applicants. NA= Not applicable because state does not provide a waiver or state-funded coverage to childless adults. Note: Income eligibility listed for children is the highest level reported among regular Medicaid, SCHIP-funded Medicaid expansion program, or separate state program. DATA: Uninsured—2008–09 CPS ASEC Supplement; Children eligibility—Kaiser Commission on Medicaid and the Uninsured, Challenges of Providing Health Coverage for Children and Parents in a Recession: A 50 State Update on Eligibility Rules, Enrollment and Renewal Procedures, and Cost-Sharing Practices in Medicaid and SCHIP in 200, Jan. 2009; Parents and childless adults eligibility—Kaiser Commission on Medicaid and the Uninsured, Expanding Health Coverage for Low-Income Adults: Filling the Gaps in Medicaid Eligibility, May 2009. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 78 EXHIBIT A8 Prevention and Treatment: Dimension and Indicator Ranking on Effective Care, Preve Coordinated Care, and Patient-Centered Care Coor g vin s rge on Mo ha at i or isc lic n State Rank ing t io tD mp s re res ine it ica ite sa Ca Top Quartile lk Co re So V is acc ed Wa os on re un are Ca or nt re Second Quartile ain Ca t al mp dV gf c ti mm re ve ts of eC ssu me en st r en lth t in Ca t ru Pr e de Co r ce in Third Quartile tiv Co Pr e &D at i Re Pa Ho ea Ra en ve Ins lit y ou en to od Bottom Quartile hP lH nt i me me me mm st al al lS r ev ure ar e ua Go Be nt a dic alt dic ve ua Ho Ho Ho Data Not Available co lQ cP il lC Pr e are are He Me Us Me Me Fa Re ng ng ng it a ca eti dic dic ar t me ult ult ild rsi rsi rsi rgi ild ild ild sp ab Ad Me Me He Ch Nu Nu Nu Ho Ho Ad Ch Ch Ch Su Di 2009 Ranking EFFEC TIVE CARE CO O R D I N AT E D C A R E PAT I E N T- C E N T E R E D C A R E R RANK S TAT E I N D I C AT O R R A N K I N G R 1 Maine 2 New Hampshire 3 Vermont 4 Delaware 5 Massachusetts 6 Iowa 7 Rhode Island 8 Minnesota 9 Nebraska 10 Pennsylvania 1 11 Connecticut 1 12 South Dakota 1 13 Wisconsin 1 1 14 North Dakota 15 Michigan 1 16 Hawaii 1 17 Kansas 1 18 South Carolina 1 19 Virginia 1 20 Maryland 2 21 New Jersey 2 22 New York 2 23 West Virginia 2 24 Ohio 2 25 Montana 2 26 Indiana 2 27 Tennessee 2 28 Colorado 2 29 Alabama 2 30 Missouri 3 31 District of Columbia 3 32 North Carolina 3 33 Kentucky 3 34 Washington 3 35 Utah 3 36 Florida 3 37 Idaho 3 38 Arkansas 3 3 39 Georgia 40 Alaska 4 41 Wyoming 4 42 California 4 43 Texas 4 44 Illinois 4 45 Louisiana 4 46 Oregon 4 47 Arizona 4 48 Oklahoma 4 49 Mississippi 4 50 New Mexico 5 51 Nevada 5 SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 a Som SOU 79 IT A8 E X H I B I T A 8 (continued) Prevention and Treatment: Dimension and Indicator Ranking on Effective Care, Coordinated Care, and Patient-Centered Care (continued) g vin s rge on Mo ha at i or isc lic n State Rank ing t io tD mp s re res ine it ica ite sa Ca Top Quartile lk Co re So V is acc ed ed Wa os on re un are Ca or nt re Second Quartile ain ain Ca t al mp dV gf c ti mm re ve ts of eC ssu me st r en st r en lth t in Ca t ru Pr e de Co r ce in in Third Quartile tiv Co Pr e &D at i Re Pa Pa Ho ea Ra en ve Ins lit y ou en to od Bottom Quartile hP lH nt i me me me me mm st al al lS r ev ure ar e ua Go Be nt a dic alt dic ve ua Ho Ho Ho Ho Data Not Available co lQ cP il lC Pr e are are He Me Us Me Me Fa Re ing ng ng ng it a ca eti dic dic ar t me ult ult ild rsi rsi rsi rgi ild ild ild sp ab Ad Me Me He Ch Nu Nu Nu Ho Ho Ad Ch Ch Ch Su Di Revised 2007 Rankinga EFFEC TIVE CARE CO O R D I N AT E D C A R E PAT I E N T- C E N T E R E D C A R E RANK S TAT E I N D I C AT O R R A N K I N G 1 Maine 2 Rhode Island 3 Massachusetts 4 Connecticut 5 Iowa 6 Nebraska 6 Vermont 8 New Hampshire 9 Wisconsin 10 South Dakota 11 Michigan 12 Pennsylvania 13 New Jersey 13 Minnesota 15 Kansas 16 Maryland 16 Montana 16 Hawaii 19 Alabama 20 Delaware 20 South Carolina 22 Virginia 23 North Carolina 24 Tennessee 25 North Dakota 26 Indiana 27 West Virginia 28 Illinois 29 Ohio 30 District of Columbia 31 Wyoming 32 New York 33 Missouri 34 Colorado 35 Washington 36 Kentucky 37 Georgia 38 Mississippi 38 New Mexico 40 Oregon 41 Idaho 42 Arkansas 43 Florida 44 Louisiana 45 Texas 45 Oklahoma 47 Utah 48 Arizona 49 Alaska 50 California 51 Nevada a Some state rates from the 2007 edition have been revised to match methodology used in the 2009 edition. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 80 ExHIBIT A9 Prevention and Treatment: Dimension Ranking and Performance on Indicators Note: Change in rate is expressed such that a positive value indicates performance Indicator Performance has improved and a negative value indicates performance has worsened. Percent Adults Age 50+ Received Percent Adult Diabetics Received Percent Children Ages 19–35 Months Recommended Preventive Care Recommended Preventive Care Received Five Vaccines Effective Care Current Past Actual Percent Actual Percent Actual Percent Dimension Dimension Current Change in Change in Current Change in Change in Current Change in Change in State Rank Rank Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea United States 42.3 2.6 6.6% 44.3 3.3 8.1% 80.1 -0.7 -0.9% Alabama 29 19 37.2 1.5 4.2% 39.1 -1.3 -3.2% 81.6 -1.7 -2.0% Alaska 40 49 39.7 1.2 3.1% 41.8 1.1 2.7% 78.6 3.2 4.2% Arizona 47 48 40.7 1.3 3.3% 41.5 4.7 12.8% 80.2 1.0 1.3% Arkansas 38 42 35.7 3.0 9.2% 34.2 2.0 6.2% 75.0 7.2 10.6% California 42 50 38.9 1.6 4.3% 47.5 12.4 35.4% 79.4 1.5 1.9% Colorado 28 34 45.7 4.5 10.9% 43.9 -4.5 -9.3% 78.6 -4.8 -5.8% Connecticut 11 4 51.1 3.8 8.0% 47.4 1.9 4.2% 89.3 3.2 3.7% Delaware 4 20 52.5 6.2 13.4% 49.0 -3.4 -6.5% 81.8 -2.4 -2.9% District of Columbia 31 30 43.2 -2.4 -5.3% 44.8 * * 82.8 9.3 12.7% Florida 36 43 40.6 -0.2 -0.5% 45.5 4.1 9.9% 82.4 3.1 3.9% Georgia 39 37 43.2 1.8 4.3% 44.4 3.3 8.0% 80.8 -3.9 -4.6% Hawaii 16 16 41.4 4.8 13.1% 49.3 -13.0 -20.9% 87.8 7.7 9.6% Idaho 37 41 36.0 3.4 10.4% 37.1 -0.2 -0.5% 75.8 -2.3 -2.9% Illinois 44 28 38.3 2.6 7.3% * * * 76.9 -6.6 -7.9% Indiana 26 26 37.9 1.7 4.7% 43.1 2.5 6.2% 76.8 -1.3 -1.7% Iowa 6 5 42.9 0.9 2.1% 48.7 -0.4 -0.8% 80.0 -4.9 -5.8% Kansas 17 15 41.0 1.4 3.5% * * * 81.7 -2.1 -2.5% Kentucky 33 36 40.3 5.2 14.8% 40.2 3.9 10.7% 80.9 1.2 1.5% Louisiana 45 44 37.5 0.3 0.8% 36.9 -1.5 -3.9% 77.7 1.7 2.2% Maine 1 1 48.8 2.0 4.3% 54.5 7.6 16.2% 77.6 -5.7 -6.8% Maryland 20 16 49.9 0.7 1.4% * * * 92.4 10.1 12.3% Massachusetts 5 3 49.5 2.8 6.0% * * * 83.9 -9.6 -10.3% Michigan 15 11 49.9 7.1 16.6% 44.5 * * 80.6 -2.1 -2.5% Minnesota 8 13 50.8 0.6 1.2% 66.9 4.5 7.2% 84.7 -0.5 -0.6% Mississippi 49 38 35.7 2.7 8.2% 33.3 4.6 16.0% 78.7 -4.9 -5.9% Missouri 30 33 42.4 4.0 10.4% 44.2 -0.3 -0.7% 77.2 -2.1 -2.6% Montana 25 16 41.6 0.5 1.2% 47.0 -2.8 -5.6% 75.0 -4.6 -5.8% Nebraska 9 6 39.5 2.3 6.2% * * * 85.2 -3.9 -4.4% Nevada 51 51 38.8 4.5 13.1% 35.1 0.7 2.0% 66.7 0.0 0.0% New Hampshire 2 8 48.8 0.2 0.4% 54.1 2.1 4.0% 93.2 10.4 12.6% New Jersey 21 13 42.8 0.2 0.5% 43.1 0.0 0.0% 82.3 4.1 5.2% New Mexico 50 38 38.5 -0.2 -0.5% 45.5 -3.7 -7.5% 78.9 0.5 0.6% New York 22 32 45.8 3.9 9.3% 46.6 4.2 9.9% 83.0 1.4 1.7% North Carolina 32 23 48.0 2.3 5.0% 45.8 -1.2 -2.6% 80.0 -5.2 -6.1% North Dakota 14 25 40.6 1.8 4.6% 54.2 9.7 21.8% 81.7 -3.3 -3.9% Ohio 24 29 43.1 4.9 12.9% 42.7 3.7 9.5% 80.4 -3.7 -4.4% Oklahoma 48 45 35.0 0.8 2.3% 40.6 3.4 9.1% 80.1 4.4 5.8% Oregon 46 40 43.7 3.7 9.2% 50.0 * * 72.4 -0.5 -0.7% Pennsylvania 10 12 43.4 5.1 13.3% 47.5 1.5 3.3% 81.4 -1.8 -2.2% Rhode Island 7 2 50.5 1.9 3.9% * * * 80.0 -3.1 -3.7% South Carolina 18 20 43.1 1.4 3.4% 39.9 -1.4 -3.4% 81.1 2.6 3.3% South Dakota 12 10 40.7 1.2 3.0% 50.1 -4.8 -8.7% 87.1 0.2 0.2% Tennessee 27 24 42.4 2.4 6.0% 46.7 -1.0 -2.1% 80.5 -2.4 -2.9% Texas 43 45 38.9 4.0 11.5% 38.5 4.3 12.6% 78.2 -0.2 -0.3% Utah 35 47 39.5 1.9 5.1% 40.0 -0.6 -1.5% 78.5 4.4 5.9% Vermont 3 6 49.3 4.9 11.0% 55.3 9.8 21.6% 79.8 -1.7 -2.1% Virginia 19 22 49.3 4.2 9.3% 46.3 1.9 4.3% 79.6 -6.2 -7.2% Washington 34 35 46.0 4.0 9.5% 50.7 3.1 6.5% 73.9 -3.9 -5.0% West Virginia 23 27 41.3 3.8 10.1% 41.4 1.0 2.5% 80.7 5.8 7.7% Wisconsin 13 9 45.3 1.5 3.4% 54.3 4.5 9.0% 79.4 -2.8 -3.4% Wyoming 41 31 37.3 0.1 0.3% 42.0 1.5 3.7% 76.8 -1.8 -2.3% 5% 5% 5% Any change or Any change or Any change change more change more change or more Number of states with trends: 51 51 42 42 51 51 Rate improved (+) 48 26 26 18 20 9 Rate worsened (-) 3 1 15 6 30 10 Little/no change in rate 0 24 1 18 1 32 a A positive or negative value indicates that current performance is better or worse. b Current and past data are not comparable because of changes in survey design. * Data could not be updated for this state. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 81 E x H I B I T A 9 (continued) Prevention and Treatment: Dimension Ranking and Performance on Indicators (continued) Note: Change in rate is expressed such Indicator Performance that a positive value Percent Hospitalized Patients indicates performance Percent Children with Received Recommended Percent Surgical Patients Percent Home Health has improved and Medical and Dental Percent Children Received Care for Heart Attack, Heart Received Appropriate Care to Patients Better at Walking a negative value Preventive Care Visits b Needed Mental Health Care Failure, and Pneumonia Prevent Complications or Moving Around indicates performance Effective Care has worsened. Actual Percent Actual Percent Actual Percent Actual Percent Actual Percent Current Change in Change in Current Change in Change in Current Change in Change in Current Change in Change in Current Change in Change in State Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea United States 71.6 —b —b 60.0 1.3 2.2% 91.3 8.5 10.3% 84.6 15.2 21.9% 40.3 3.4 9.2% Alabama 69.9 —b —b 61.7 -5.3 -7.9% 91.4 8.3 10.0% 83.2 12.0 16.9% 42.8 4.0 10.3% Alaska 70.7 —b —b 63.0 10.8 20.7% 92.0 5.7 6.6% 81.5 15.8 24.1% 33.8 1.2 3.7% Arizona 67.4 —b —b 62.1 7.1 12.9% 90.1 6.1 7.3% 82.5 15.5 23.1% 37.6 2.6 7.4% Arkansas 65.0 —b —b 56.5 8.8 18.4% 92.2 11.2 13.8% 82.9 14.2 20.7% 39.5 4.9 14.2% California 71.5 —b —b 53.5 -0.5 -0.9% 90.9 11.4 14.3% 80.4 21.7 36.9% 41.4 3.5 9.2% Colorado 70.0 —b —b 64.8 7.9 13.9% 93.4 5.9 6.7% 85.2 13.6 19.0% 37.4 2.3 6.6% Connecticut 82.4 —b —b 78.8 4.7 6.3% 91.6 4.8 5.5% 89.7 -0.3 -0.3% 38.4 4.1 12.0% Delaware 72.7 —b —b 76.9 20.2 35.6% 92.4 8.7 10.4% 87.0 13.7 18.7% 37.3 5.9 18.8% District of Columbia 82.0 —b —b 56.5 -9.6 -14.5% 84.9 6.5 8.3% 81.5 15.4 23.3% 39.2 7.4 23.3% Florida 64.7 —b —b 52.0 -2.7 -4.9% 91.1 9.7 11.9% 84.4 15.6 22.7% 41.6 4.4 11.8% Georgia 73.3 —b —b 51.2 -9.6 -15.8% 89.5 10.1 12.7% 81.8 17.7 27.6% 45.2 5.7 14.4% Hawaii 80.3 —b —b 62.8 -3.3 -5.0% 87.5 6.8 8.4% 78.3 20.9 36.4% 40.5 1.6 4.1% Idaho 60.2 —b —b 63.4 6.5 11.4% 94.5 8.6 10.0% 83.3 10.5 14.4% 39.9 5.4 15.7% Illinois 73.7 —b —b 53.0 -10.0 -15.9% 90.7 7.5 9.0% 84.6 16.4 24.1% 39.0 1.5 4.0% Indiana 70.3 —b —b 64.3 -1.8 -2.7% 92.7 8.2 9.7% 85.8 20.5 31.4% 39.3 1.4 3.7% Iowa 75.4 —b —b 74.5 6.9 10.2% 94.9 6.6 7.5% 86.8 9.1 11.7% 34.8 1.8 5.5% Kansas 73.9 —b —b 72.3 11.0 17.9% 90.1 2.6 3.0% 83.8 15.5 22.7% 42.0 6.1 17.0% Kentucky 70.9 —b —b 65.5 3.0 4.8% 91.1 9.6 11.8% 81.8 11.3 16.0% 42.6 4.6 12.1% Louisiana 69.6 —b —b 55.3 11.1 25.1% 89.6 7.9 9.7% 81.1 20.2 33.2% 42.6 6.1 16.7% Maine 75.8 —b —b 70.8 3.2 4.7% 93.4 8.7 10.3% 92.7 16.4 21.5% 40.9 3.0 7.9% Maryland 75.8 —b —b 59.4 0.5 0.8% 89.2 5.7 6.8% 84.6 13.8 19.5% 41.8 3.5 9.1% Massachusetts 82.6 —b —b 66.6 -1.0 -1.5% 91.8 6.7 7.9% 90.3 13.4 17.4% 40.9 5.8 16.5% Michigan 74.6 —b —b 60.4 -3.4 -5.3% 92.6 6.6 7.7% 89.4 12.0 15.5% 40.3 2.8 7.5% Minnesota 67.5 —b —b 67.0 2.4 3.7% 93.3 7.4 8.6% 88.2 13.1 17.4% 33.8 0.7 2.1% Mississippi 64.2 —b —b 43.0 -7.1 -14.2% 89.8 10.0 12.5% 79.3 16.9 27.1% 43.2 3.9 9.9% Missouri 66.7 —b —b 73.9 13.7 22.8% 92.9 8.1 9.6% 85.1 14.1 19.8% 42.2 5.0 13.4% Montana 64.1 —b —b 67.9 -0.5 -0.7% 93.3 5.9 6.8% 89.7 7.8 9.5% 41.4 6.5 18.6% Nebraska 68.7 —b —b 71.0 -1.8 -2.5% 95.1 7.1 8.1% 90.8 13.8 17.9% 40.0 4.5 12.7% Nevada 61.1 —b —b 53.1 -0.1 -0.2% 90.2 9.0 11.1% 80.5 29.8 58.7% 42.0 3.3 8.5% New Hampshire 81.0 —b —b 63.0 -0.5 -0.8% 95.6 10.4 12.2% 91.7 23.1 33.7% 38.6 2.7 7.5% New Jersey 77.6 —b —b 55.2 -3.5 -6.0% 93.7 6.8 7.8% 87.1 10.0 13.0% 44.1 4.8 12.2% New Mexico 71.2 —b —b 53.5 -4.8 -8.2% 88.5 4.1 4.9% 78.5 8.4 12.0% 43.2 3.4 8.5% New York 79.3 —b —b 61.1 4.0 7.0% 90.9 8.1 9.8% 87.3 18.7 27.3% 36.1 1.7 4.9% North Carolina 71.4 —b —b 61.7 -1.9 -3.0% 90.8 8.2 9.9% 85.7 11.9 16.1% 40.8 2.4 6.3% North Dakota 62.2 —b —b 72.4 6.3 9.5% 95.6 8.9 10.3% 88.2 10.3 13.2% 42.4 7.0 19.8% Ohio 72.3 —b —b 66.2 5.0 8.2% 92.8 7.8 9.2% 87.5 22.3 34.2% 38.3 2.1 5.8% Oklahoma 67.6 —b —b 53.6 5.4 11.2% 93.3 8.0 9.4% 84.4 3.7 4.6% 38.2 3.9 11.4% Oregon 62.3 —b —b 46.2 -16.5 -26.3% 90.2 5.8 6.9% 82.5 9.4 12.9% 36.3 0.3 0.8% Pennsylvania 78.9 —b —b 81.5 5.7 7.5% 91.1 10.5 13.0% 86.1 22.7 35.8% 42.9 3.9 10.0% Rhode Island 85.3 —b —b 76.0 8.5 12.6% 90.8 2.5 2.8% 90.2 4.8 5.6% 37.3 4.2 12.7% South Carolina 74.3 —b —b 62.7 2.9 4.8% 93.5 9.7 11.6% 87.0 12.7 17.1% 45.0 3.2 7.7% South Dakota 65.2 —b —b 69.3 -1.7 -2.4% 94.6 7.0 8.0% 90.4 13.0 16.8% 41.1 5.4 15.1% Tennessee 70.9 —b —b 64.1 2.2 3.6% 90.9 7.6 9.1% 82.1 14.8 22.0% 47.4 6.9 17.0% Texas 67.3 —b —b 41.7 -1.7 -3.9% 91.1 10.5 13.0% 81.4 19.2 30.9% 38.6 2.5 6.9% Utah 64.8 —b —b 66.8 7.6 12.8% 90.9 6.9 8.2% 85.7 19.7 29.8% 48.2 6.8 16.4% Vermont 79.4 —b —b 69.3 -0.7 -1.0% 94.5 6.2 7.0% 91.0 18.9 26.2% 38.8 3.0 8.4% Virginia 72.1 —b —b 72.2 10.4 16.8% 92.0 10.0 12.2% 85.3 16.4 23.8% 42.1 3.0 7.7% Washington 71.0 —b —b 62.4 6.0 10.6% 90.1 6.6 7.9% 86.9 14.6 20.2% 39.3 3.3 9.2% West Virginia 74.4 —b —b 72.0 8.7 13.7% 91.2 9.7 11.9% 83.3 13.8 19.9% 44.9 3.8 9.2% Wisconsin 68.2 —b —b 61.4 -5.4 -8.1% 93.6 6.7 7.7% 90.2 17.4 23.9% 37.9 3.3 9.5% Wyoming 68.1 —b —b 67.6 -9.6 -12.4% 93.4 8.3 9.8% 85.6 16.5 23.9% 34.6 -4.3 -11.1% 5% 5% 5% 5% 5% Any change Any change Any change Any change Any change change or more change or more change or more change or more change or more Number of states with trends: —b —b 51 51 51 51 51 51 51 51 Rate improved (+) —b —b 27 21 51 48 50 49 50 43 Rate worsened (-) —b —b 24 12 0 0 1 0 1 1 Little/no change in rate —b —b 0 18 0 3 0 2 0 7 a A positive or negative value indicates that current performance is better or worse. b Current and past data are not comparable because of changes in survey design. * Data could not be updated for this state. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 82 E x H I B I T A 9 (continued) Prevention and Treatment: Dimension Ranking and Performance on Indicators (continued) Note: Change in rate is expressed such Indicator Performance that a positive value indicates performance has improved and Percent Heart Failure Patients Given a negative value Percent Adults with a Usual Source of Care Percent Children with a Medical Homeb Instructions at Discharge indicates performance Coordinated Care has worsened. Actual Percent Actual Percent Actual Percent Current Change in Change in Current Change in Change in Current Change in Change in State Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea United States 79.7 0.5 0.6% 57.5 —b —b 74.7 24.1 47.6% Alabama 81.5 1.1 1.4% 56.1 —b —b 74.2 24.0 47.8% Alaska 69.3 -1.7 -2.4% 52.3 —b —b 53.8 26.5 96.9% Arizona 72.7 -0.9 -1.2% 50.0 —b —b 66.3 25.5 62.4% Arkansas 82.2 0.1 0.1% 60.7 —b —b 77.4 23.4 43.4% California 72.2 0.3 0.4% 49.6 —b —b 75.0 30.8 69.7% Colorado 78.1 -1.0 -1.3% 59.3 —b —b 78.1 37.2 90.9% Connecticut 86.3 0.0 0.0% 62.4 —b —b 70.6 6.7 10.5% Delaware 89.0 0.3 0.3% 59.9 —b —b 84.2 39.6 88.8% District of Columbia 79.7 2.2 2.8% 49.7 —b —b 63.6 3.5 5.8% Florida 76.6 1.2 1.6% 56.8 —b —b 75.3 26.7 54.9% Georgia 79.2 1.6 2.1% 58.5 —b —b 69.6 21.3 44.0% Hawaii 85.9 5.2 6.4% 60.1 —b —b 65.4 36.3 124.7% Idaho 71.7 -1.8 -2.4% 56.1 —b —b 84.8 27.6 48.3% Illinois 81.8 -1.3 -1.6% 55.9 —b —b 76.5 20.9 37.6% Indiana 83.5 -0.5 -0.6% 61.7 —b —b 80.8 28.0 53.1% Iowa 84.6 -0.2 -0.2% 66.9 —b —b 81.6 14.9 22.3% Kansas 83.9 0.0 0.0% 61.3 —b —b 68.8 12.5 22.2% Kentucky 83.5 1.0 1.2% 61.8 —b —b 71.4 30.7 75.4% Louisiana 77.6 0.9 1.2% 55.3 —b —b 70.0 18.2 35.1% Maine 88.8 0.5 0.6% 65.5 —b —b 81.5 21.7 36.3% Maryland 84.2 0.6 0.7% 58.6 —b —b 78.0 21.0 36.8% Massachusetts 88.5 1.6 1.8% 66.2 —b —b 75.1 23.4 45.2% Michigan 85.0 1.3 1.6% 62.5 —b —b 79.6 17.8 28.8% Minnesota 78.1 3.2 4.3% 63.0 —b —b 76.6 17.0 28.5% Mississippi 78.0 0.6 0.8% 51.6 —b —b 68.7 18.9 38.0% Missouri 82.1 -1.1 -1.3% 64.8 —b —b 73.3 23.3 46.6% Montana 72.1 -1.9 -2.6% 61.5 —b —b 68.6 22.3 48.2% Nebraska 84.4 1.3 1.6% 69.1 —b —b 81.5 26.6 48.4% Nevada 69.2 3.6 5.5% 45.4 —b —b 67.8 42.7 170.3% New Hampshire 88.0 0.4 0.5% 69.3 —b —b 85.0 23.6 38.4% New Jersey 83.5 0.8 1.0% 56.8 —b —b 84.0 15.9 23.3% New Mexico 74.1 -1.5 -2.0% 49.0 —b —b 53.8 39.5 277.3% New York 84.1 1.7 2.1% 56.9 —b —b 77.5 35.4 84.0% North Carolina 77.8 -1.5 -1.9% 60.9 —b —b 74.3 22.2 42.6% North Dakota 75.7 -0.5 -0.7% 64.0 —b —b 88.8 44.2 99.2% Ohio 84.4 -0.2 -0.2% 66.2 —b —b 81.1 20.3 33.4% Oklahoma 78.8 0.5 0.6% 55.7 —b —b 72.9 28.7 65.0% Oregon 77.6 1.4 1.8% 63.4 —b —b 66.3 32.2 94.3% Pennsylvania 89.0 0.0 0.0% 61.9 —b —b 72.4 24.7 51.8% Rhode Island 85.7 0.6 0.7% 63.6 —b —b 73.8 3.8 5.4% South Carolina 82.0 0.5 0.6% 58.8 —b —b 78.2 22.9 41.4% South Dakota 79.6 -3.4 -4.1% 63.3 —b —b 91.4 7.2 8.6% Tennessee 83.6 1.4 1.7% 61.4 —b —b 70.8 20.1 39.7% Texas 71.5 -0.4 -0.6% 50.3 —b —b 74.5 27.1 57.1% Utah 76.9 3.7 5.1% 63.0 —b —b 79.4 34.3 76.1% Vermont 86.8 0.4 0.5% 67.2 —b —b 82.3 27.5 50.1% Virginia 82.1 0.3 0.4% 58.8 —b —b 76.1 27.0 55.0% Washington 78.3 0.0 0.0% 59.9 —b —b 70.7 34.8 96.8% West Virginia 78.8 1.1 1.4% 64.6 —b —b 77.4 13.5 21.1% Wisconsin 85.2 2.3 2.8% 62.9 —b —b 76.2 15.1 24.7% Wyoming 73.4 -1.9 -2.5% 59.3 —b —b 70.2 31.6 81.8% 5% 5% 5% change change change Any change or more Any change or more Any change or more Number of states with trends: 51 51 —b —b 51 51 Rate improved (+) 31 3 —b —b 51 51 Rate worsened (-) 16 0 —b —b 0 0 Little/no change in rate 4 48 —b —b 0 0 a A positive or negative value indicates that current performance is better or worse. b Current and past data are not comparable because of changes in survey design. * Data could not be updated for this state. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 83 E x H I B I T A 9 (continued) Prevention and Treatment: Dimension Ranking and Performance on Indicators (continued) Note: Change in rate is expressed such Indicator Performance that a positive value indicates performance Percent Medicare Patients Percent Medicare Patients Percent High-Risk Percent Long-Stay Percent Long-Stay Nursing has improved and Experienced Good Giving Best Rating Nursing Home Residents Nursing Home Residents Home Residents with a negative value Communication with Provider for Care Received with Pressure Sores Physically Restrained Moderate to Severe Pain indicates performance Patient-Centered Care has worsened. Actual Percent Actual Percent Actual Percent Actual Percent Actual Percent Current Change in Change in Current Change in Change in Current Change in Change in Current Change in Change in Current Change in Change in State Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea United States NA NA NA NA NA NA 12.0 1.4 10.4% 5.1 2.3 31.1% 4.4 2.0 31.3% Alabama 75.2 5.9 8.5% 60.7 -11.2 -15.6% 9.8 1.9 16.2% 2.8 2.2 44.5% 3.3 2.4 42.1% Alaska 74.9 7.3 10.8% 59.6 -5.8 -8.9% 9.8 3.5 26.4% 1.8 3.7 67.3% 5.6 4.6 45.1% Arizona 71.7 8.6 13.6% 55.0 -9.3 -14.5% 10.5 0.5 4.5% 4.7 4.3 47.4% 5.7 2.9 33.7% Arkansas 75.1 5.6 8.1% 58.9 -12.3 -17.3% 11.7 1.0 7.9% 11.0 4.9 30.7% 3.3 2.2 40.7% California 72.0 5.4 8.1% 61.1 -6.8 -10.0% 13.2 0.4 3.0% 10.7 4.7 30.5% 4.5 1.1 20.0% Colorado 74.5 8.6 13.0% 61.1 -1.3 -2.1% 8.6 1.1 11.3% 5.0 1.4 21.9% 4.7 4.3 47.8% Connecticut 73.6 5.0 7.3% 61.8 -9.3 -13.1% 11.0 2.2 16.6% 3.9 3.4 46.6% 3.3 1.2 26.7% Delaware 78.0 11.1 16.6% 69.3 0.6 0.9% 12.3 2.2 15.1% 1.5 1.1 42.6% 4.0 1.6 28.6% District of Columbia 75.1 4.1 5.8% 62.8 -4.7 -7.0% 14.6 4.8 24.8% 1.6 0.9 36.4% 0.9 0.7 43.8% Florida 72.5 7.4 11.4% 60.2 -6.8 -10.1% 12.9 1.3 9.2% 7.0 2.4 25.5% 3.9 2.5 39.1% Georgia 71.5 3.3 4.8% 59.7 -10.9 -15.4% 13.6 1.5 10.0% 5.7 4.5 44.2% 5.8 2.8 32.9% Hawaii 77.4 5.6 7.8% 66.0 -8.3 -11.2% 7.6 1.4 15.6% 2.9 0.7 19.8% 2.2 0.8 26.7% Idaho 72.7 5.5 8.2% 60.0 -10.3 -14.7% 8.8 -0.5 -6.0% 4.3 1.9 30.7% 5.2 2.9 35.8% Illinois * * * * * * 15.0 1.4 8.5% 4.0 0.7 14.8% 5.6 0.4 6.7% Indiana 74.9 6.0 8.7% 63.5 -7.0 -9.9% 11.6 2.8 19.4% 4.4 1.4 24.0% 4.1 2.0 33.3% Iowa 74.5 6.0 8.8% 67.6 -2.9 -4.1% 8.0 0.8 9.0% 1.8 0.8 31.5% 4.7 2.1 31.3% Kansas 76.1 7.8 11.4% 65.3 -6.2 -8.7% 8.9 3.2 26.3% 1.8 1.8 50.6% 4.8 3.7 43.5% Kentucky 73.0 4.3 6.3% 58.9 -9.6 -14.0% 12.5 1.3 9.5% 5.4 1.5 21.7% 4.7 2.3 32.9% Louisiana 76.8 4.4 6.1% 68.3 -3.5 -4.9% 17.2 0.8 4.4% 9.9 4.2 29.7% 5.1 1.8 26.1% Maine 76.9 3.5 4.8% 66.2 -7.2 -9.8% 8.1 2.4 22.9% 2.1 2.7 57.2% 3.2 2.1 39.6% Maryland 74.9 6.7 9.8% 60.3 -7.4 -10.9% 13.1 0.9 6.4% 3.8 2.9 43.7% 2.0 1.0 33.3% Massachusetts 75.1 3.5 4.9% 62.5 -9.3 -13.0% 10.9 2.4 18.0% 4.7 2.0 29.8% 2.5 2.0 44.4% Michigan 75.0 6.3 9.2% 63.3 -8.0 -11.2% 10.8 1.9 15.0% 5.0 1.6 24.2% 4.2 2.0 32.3% Minnesota 77.4 8.2 11.9% 66.4 -4.3 -6.1% 7.7 1.3 14.5% 2.3 2.3 50.9% 3.6 3.7 50.7% Mississippi 76.5 6.1 8.7% 57.2 -14.4 -20.1% 12.8 -0.6 -4.9% 7.7 4.1 34.6% 4.1 0.6 12.8% Missouri 72.0 3.6 5.3% 62.5 -6.6 -9.6% 11.6 1.9 14.0% 5.9 1.2 17.0% 4.8 2.2 31.4% Montana 75.5 3.3 4.6% 61.1 -13.3 -17.9% 7.5 0.2 2.6% 2.2 0.8 26.9% 5.5 1.6 22.5% Nebraska 72.7 1.5 2.1% 64.0 -7.2 -10.1% 8.1 0.0 0.0% 1.5 0.4 20.8% 4.9 3.6 42.4% Nevada 73.8 7.8 11.8% 56.2 -9.7 -14.7% 12.8 0.4 3.0% 5.9 5.4 47.9% 5.8 2.9 33.3% New Hampshire 74.2 5.8 8.5% 58.7 -11.1 -15.9% 9.4 1.8 16.2% 1.6 1.7 51.1% 3.7 2.0 35.7% New Jersey 73.6 4.5 6.5% 57.8 -10.5 -15.4% 16.9 1.5 8.2% 4.1 1.1 21.2% 2.7 1.7 39.5% New Mexico 71.5 7.1 11.0% 56.8 -4.4 -7.2% 11.7 -0.2 -1.7% 7.3 0.9 11.0% 6.0 0.8 11.8% New York 74.7 7.3 10.8% 60.9 -6.4 -9.5% 13.7 0.8 5.5% 3.6 1.1 23.1% 3.0 1.2 29.3% North Carolina 74.3 5.3 7.7% 60.0 -9.5 -13.7% 11.1 2.9 20.7% 6.9 3.0 30.4% 3.5 2.8 44.4% North Dakota 70.8 3.5 5.2% 59.7 -7.5 -11.2% 7.5 0.1 1.3% 1.9 0.6 23.4% 4.2 2.6 38.8% Ohio 73.6 5.0 7.3% 60.6 -9.4 -13.4% 11.6 1.7 12.8% 5.4 1.7 24.0% 6.6 2.6 28.3% Oklahoma 69.9 1.2 1.7% 59.6 -10.6 -15.1% 14.4 2.1 12.8% 9.1 3.6 28.4% 6.2 1.3 17.6% Oregon 72.1 4.4 6.5% 55.0 -14.0 -20.3% 10.3 0.4 3.8% 4.2 5.0 54.5% 6.5 2.2 25.3% Pennsylvania 76.7 6.5 9.3% 62.1 -10.4 -14.3% 11.6 2.1 15.4% 3.2 1.5 32.2% 3.8 1.4 26.9% Rhode Island 77.8 4.6 6.3% 65.5 -8.6 -11.6% 11.3 4.0 26.2% 2.4 1.6 40.2% 2.7 1.4 35.0% South Carolina 77.7 6.7 9.4% 61.5 -10.2 -14.2% 12.0 1.4 10.5% 6.7 3.1 31.7% 3.3 2.2 40.0% South Dakota 73.4 3.1 4.4% 64.2 -8.0 -11.1% 9.7 2.4 19.9% 2.1 2.6 54.6% 5.0 3.4 40.5% Tennessee 74.6 4.9 7.0% 64.2 -6.5 -9.2% 12.1 1.0 7.6% 7.2 3.4 32.3% 4.5 3.5 43.8% Texas 74.1 4.6 6.6% 63.6 -6.8 -9.7% 11.5 0.8 6.5% 4.3 3.5 44.5% 4.1 1.8 30.5% Utah 68.7 4.4 6.8% 59.7 -5.5 -8.4% 10.7 1.6 13.0% 8.5 3.8 30.9% 8.2 3.0 27.0% Vermont 74.5 -0.4 -0.5% 61.5 -9.7 -13.6% 9.4 6.3 40.1% 2.4 1.2 33.4% 3.6 2.2 37.9% Virginia 74.8 4.7 6.7% 61.3 -8.5 -12.2% 13.3 2.5 15.8% 2.8 1.7 37.9% 3.6 2.7 42.9% Washington 70.0 3.6 5.4% 60.0 -5.8 -8.8% 11.9 0.3 2.5% 2.1 1.8 47.0% 6.5 2.2 25.3% West Virginia 73.9 5.3 7.7% 57.0 -9.6 -14.4% 11.9 3.0 20.2% 3.5 1.1 23.9% 4.0 1.4 25.9% Wisconsin 75.1 5.1 7.3% 65.0 -5.1 -7.3% 10.1 0.5 4.7% 1.8 1.4 44.3% 3.9 1.8 31.6% Wyoming 71.0 -0.6 -0.8% 54.0 -16.9 -23.8% 10.5 1.1 9.5% 2.9 3.3 53.3% 6.8 4.6 40.4% 5% 5% 5% 5% 5% Any change Any change Any change Any change Any change change or more change or more change or more change or more change or more Number of states with trends: 50 50 50 50 51 51 51 51 51 51 Rate improved (+) 48 41 1 0 47 38 51 51 51 51 Rate worsened (-) 2 0 49 46 3 1 0 0 0 0 Little/no change in rate 0 9 0 4 1 12 0 0 0 0 a A positive or negative value indicates that current performance is better or worse. b Current and past data are not comparable because of changes in survey design. * Data could not be updated for this state. NA = Not available. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 84 ExHIBIT A10 Hospital Quality Indicator Composite Percent and Rank: Hospitalized Patients Who Received Recommended Care for Heart Attack, Heart Failure, and Pneumonia, 2007 Percent Rank Heart Heart Heart Heart State Composite Attack Failure Pneumonia Composite Attack Failure Pneumonia Alabama 91.4 94.7 82.4 88.7 27 30 36 42 Alaska 92.0 96.6 79.9 89.6 23 11 45 33 Arizona 90.1 93.9 82.4 88.2 42 40 36 44 Arkansas 92.2 94.6 85.2 90.4 22 33 29 25 California 90.9 94.7 85.4 89.4 33 30 28 36 Colorado 93.4 97.2 87.2 90.4 11 7 16 25 Connecticut 91.6 96.3 87.5 91.3 26 15 14 12 Delaware 92.4 96.1 90.9 90.9 21 17 4 18 District of Columbia 84.9 93.2 80.8 81.5 51 47 42 51 Florida 91.1 93.8 86.2 90.7 29 42 24 22 Georgia 89.5 93.2 82.1 87.7 47 47 38 46 Hawaii 87.5 94.0 80.2 87.0 50 39 44 48 Idaho 94.5 97.1 86.8 91.2 6 8 20 14 Illinois 90.7 93.8 87.1 89.0 39 42 17 39 Indiana 92.7 95.5 87.6 91.1 19 24 13 16 Iowa 94.9 97.7 85.6 92.5 4 5 27 5 Kansas 90.1 94.5 71.1 85.7 42 35 51 49 Kentucky 91.1 93.9 79.4 89.5 29 40 47 34 Louisiana 89.6 93.4 81.6 87.9 46 45 40 45 Maine 93.4 96.6 90.2 93.9 11 11 5 3 Maryland 89.2 93.7 88.2 89.2 48 44 10 37 Massachusetts 91.8 96.2 87.0 90.9 25 16 18 18 Michigan 92.6 95.7 87.8 91.6 20 20 11 8 Minnesota 93.3 96.7 84.3 90.0 14 9 30 32 Mississippi 89.8 91.3 77.8 88.6 45 51 48 43 Missouri 92.9 96.0 81.7 90.3 17 18 39 28 Montana 93.3 96.4 82.7 91.6 14 14 35 8 Nebraska 95.1 97.8 86.6 90.9 3 3 23 18 Nevada 90.2 94.4 83.7 87.3 40 37 32 47 New Hampshire 95.6 98.0 91.3 94.8 1 1 2 2 New Jersey 93.7 95.6 91.5 93.9 8 22 1 3 New Mexico 88.5 93.1 71.9 85.7 49 49 50 49 New York 90.9 95.0 87.8 90.3 33 28 11 28 North Carolina 90.8 94.5 86.0 91.1 37 35 25 16 North Dakota 95.6 97.5 91.3 90.7 1 6 2 22 Ohio 92.8 95.5 88.8 92.0 18 24 8 7 Oklahoma 93.3 94.8 79.9 90.4 14 29 45 25 Oregon 90.2 95.6 80.8 90.1 40 22 42 31 Pennsylvania 91.1 94.7 84.3 90.9 29 30 30 18 Rhode Island 90.8 95.4 87.4 91.3 37 26 15 12 South Carolina 93.5 95.8 86.9 91.2 10 19 19 14 South Dakota 94.6 97.8 89.0 89.1 5 3 7 38 Tennessee 90.9 94.6 81.0 90.6 33 33 41 24 Texas 91.1 94.2 83.5 89.5 29 38 33 34 Utah 90.9 93.3 88.3 90.3 33 46 9 28 Vermont 94.5 98.0 90.0 94.9 6 1 6 1 Virginia 92.0 95.7 86.7 91.5 23 20 21 10 Washington 90.1 95.1 83.2 88.9 42 27 34 40 West Virginia 91.2 92.7 85.8 88.9 28 50 26 40 Wisconsin 93.6 96.7 86.7 92.1 9 9 21 6 Wyoming 93.4 96.5 77.1 91.4 11 13 49 11 Note: See Appendix B for description of clinical indicators. DATA: 2007 CMS Hospital Compare data SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 85 EXHIBIT A11 Avoidable Hospital Use and Costs: Dimension and Indicator Ranking State Rank it Top Quartile s Vis ion e lle om Second Quartile dit nro Ro on ium ma Third Quartile rE s SC cy on pe sth rem ex s en Bottom Quartile AC on ssi nts nd cA s erg eP on s ssi mi or Data Not Available ion yI me tri ssi Em nc sf ad mi sit dia iss rse on ura mi Re ad en an dm Pe ssi Ad bu Re ay ns Int 2009 Ranking th mi hA or im hI -D me me wi are sf Ad Re 30 alt alt Ho Ho cs on lC He are are are ati He ng ng ssi ita thm gle dic dic dic me mi rsi rsi sp Sin Me Me Me Nu Nu Ho Ho Ad As P O T E N T I A L LY AVO I DA B L E H O S P I TA L U S E CO S T S RANK S TAT E I N D I C AT O R R A N K I N G 1 Utah 2 Idaho 3 Oregon 4 North Dakota 5 Hawaii 6 Washington 7 Montana 7 South Dakota 9 Wyoming 10 New Mexico 11 Vermont 12 Minnesota 13 Nebraska 14 Iowa 15 Colorado 16 Wisconsin 17 Alaska 18 Maine 18 Arizona 20 New Hampshire 21 Virginia 22 California 23 Kansas 24 Georgia 25 North Carolina 26 Indiana 27 Nevada 28 Missouri 29 South Carolina 29 Maryland 31 Pennsylvania 32 Connecticut 33 Massachusetts 34 Ohio 35 Florida 36 Rhode Island 37 Alabama 38 Delaware 39 Arkansas 40 Michigan 41 Tennessee 42 Texas 43 Kentucky 44 Oklahoma 45 Mississippi 46 District of Columbia 47 West Virginia 48 New Jersey 49 Illinois 50 New York 51 Louisiana 86 E X H I B I T A 1 1 (continued) Avoidable Hospital Use and Costs: Dimension and Indicator Ranking (continued) State Rank it Top Quartile s Vis ion e lle om Second Quartile dit nro Ro on ium ma Third Quartile rE s SC cy on pe sth rem ex s en Bottom Quartile AC on ssi nts nd cA s erg eP on s ssi mi or Data Not Available ion yI me tri ssi Em nc sf ad mi sit dia iss rse on ura mi Re ad en an dm Pe ssi Ad bu Re ay ns Int Revised 2007 Rankinga th mi hA or im hI -D me me wi are sf Ad Re 30 alt alt Ho Ho cs on lC He are are are ati He ssi ng ng ita thm gle dic dic dic me mi rsi rsi sp Sin Me Me Me Nu Nu Ho Ho Ad As P O T E N T I A L LY AVO I DA B L E H O S P I TA L U S E CO S T S RANK S TAT E I N D I C AT O R R A N K I N G 1 Utah 2 Oregon 3 Idaho 4 Washington 5 Hawaii 6 North Dakota 7 New Mexico 8 Montana 9 Vermont 10 Minnesota 11 Wyoming 12 Iowa 13 Nebraska 14 Wisconsin 15 Colorado 16 Arizona 17 South Dakota 18 New Hampshire 19 Maine 20 Alaska 21 California 22 North Carolina 23 Indiana 24 Virginia 25 Georgia 26 Connecticut 27 Kansas 28 Missouri 29 Rhode Island 30 South Carolina 31 Maryland 32 Michigan 33 Nevada 34 Florida 35 Delaware 36 Massachusetts 37 Ohio 38 Pennsylvania 39 Alabama 40 Tennessee 41 Illinois 42 Kentucky 42 New York 44 West Virginia 45 Arkansas 46 Texas 47 New Jersey 48 Oklahoma 49 Mississippi 50 District of Columbia 51 Louisiana a 87 ExHIBIT A12 Avoidable Hospital Use and Costs: Dimension Ranking and Performance on Indicators Note: Change in rate is expressed such that a positive value indicates performance Indicator Performance has improved and a negative value indicates performance has worsened. Percent Adult Asthmatics Hospital Admissions for Pediatric with Emergency Room Medicare Admissions for ACS Asthma per 100,000 Children or Urgent Care Visitb Conditions per 100,000 Beneficiaries Avoidable Hospital Use Current Past Actual Percent Actual Percent Actual Percent Dimension Dimension Current Change in Change in Current Change in Change in Current Change in Change in State Rank Rank Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea United States 164.9 13.2 7.4% 17.6 —b —b 6,587 705 9.7% Alabama 37 39 * * * * —b —b 7,633 1,117 12.8% Alaska 17 20 * * * 13.1 —b —b 4,867 300 5.8% Arizona 18 16 119.7 33.7 22.0% 15.5 —b —b 4,657 530 10.2% Arkansas 39 45 109.3 * * * —b —b 7,727 762 9.0% California 22 21 98.2 22.0 18.3% 18.3 —b —b 5,360 651 10.8% Colorado 15 15 135.5 22.5 14.2% * —b —b 4,917 394 7.4% Connecticut 32 26 149.1 * * 16.6 —b —b 6,389 -42 -0.7% Delaware 38 35 * * * 21.6 —b —b 5,427 1,176 17.8% District of Columbia 46 50 * * * 26.3 —b —b 7,257 1,403 16.2% Florida 35 34 156.9 48.6 23.6% * —b —b 5,795 717 11.0% Georgia 24 25 147.0 -13.1 -9.8% 20.2 —b —b 6,291 1,588 20.2% Hawaii 5 5 81.0 2.1 2.5% 13.1 —b —b 4,144 70 1.7% Idaho 2 3 * * * 11.6 —b —b 4,485 327 6.8% Illinois 49 41 124.2 23.8 16.1% * —b —b 7,553 595 7.3% Indiana 26 23 106.9 * * 19.2 —b —b 7,118 554 7.2% Iowa 14 12 81.0 5.9 6.8% 12.3 —b —b 5,981 50 0.8% Kansas 23 27 139.7 14.0 9.1% * —b —b 6,826 88 1.3% Kentucky 43 42 203.6 26.9 11.7% 19.2 —b —b 8,576 1,413 14.1% Louisiana 51 51 * * * 21.2 —b —b 9,331 1,088 10.4% Maine 18 19 * * * * —b —b 5,992 56 0.9% Maryland 29 31 143.8 37.8 20.8% 16.1 —b —b 6,182 1,355 18.0% Massachusetts 33 36 125.5 49.8 28.4% 13.7 —b —b 7,262 131 1.8% Michigan 40 32 188.1 -7.4 -4.1% 17.1 —b —b 6,829 144 2.1% Minnesota 12 10 102.2 16.7 14.0% 12.6 —b —b 4,749 614 11.4% Mississippi 45 49 * * * 29.7 —b —b 7,844 2,703 25.6% Missouri 28 28 167.2 7.3 4.2% 18.7 —b —b 7,256 514 6.6% Montana 7 8 * * * 15.1 —b —b 6,221 421 6.3% Nebraska 13 13 100.0 -13.2 -15.2% * —b —b 5,708 408 6.7% Nevada 27 33 107.4 26.8 20.0% * —b —b 4,857 483 9.0% New Hampshire 20 18 56.5 9.5 14.4% 15.9 —b —b 6,054 -321 -5.6% New Jersey 48 47 155.8 49.3 24.0% 16.4 —b —b 7,350 597 7.5% New Mexico 10 7 * * * 15.5 —b —b 5,308 160 2.9% New York 50 42 253.5 36.0 12.4% 21.2 —b —b 7,269 310 4.1% North Carolina 25 22 124.5 23.4 15.8% 27.1 —b —b 6,401 783 10.9% North Dakota 4 6 * * * * —b —b 6,232 89 1.4% Ohio 34 37 135.3 17.3 11.3% 19.2 —b —b 7,608 663 8.0% Oklahoma 44 48 * * * 18.4 —b —b 7,256 1,624 18.3% Oregon 3 2 48.6 6.4 11.6% * —b —b 3,862 900 18.9% Pennsylvania 31 38 * * * 14.9 —b —b 6,924 1,231 15.1% Rhode Island 36 29 143.8 12.3 7.9% 16.2 —b —b 8,893 -715 -8.7% South Carolina 29 30 167.8 38.3 18.6% * —b —b 6,395 875 12.0% South Dakota 7 17 * * * 12.5 —b —b 6,403 442 6.5% Tennessee 41 40 154.1 -9.7 -6.7% * —b —b 7,593 1,512 16.6% Texas 42 46 138.6 24.0 14.8% 16.5 —b —b 7,137 847 10.6% Utah 1 1 81.6 -4.0 -5.2% 10.8 —b —b 3,725 581 13.5% Vermont 11 9 50.2 14.3 22.2% 12.4 —b —b 4,963 239 4.6% Virginia 21 24 * * * 20.9 —b —b 5,913 884 13.0% Washington 6 4 114.5 -27.9 -32.2% 11.9 —b —b 4,478 21 0.5% West Virginia 47 44 148.7 54.4 26.8% * —b —b 9,195 782 7.8% Wisconsin 16 14 109.1 7.6 6.5% 14.5 —b —b 5,872 123 2.1% Wyoming 9 11 * * * * —b —b 4,473 771 14.7% 5% 5% 5% Any change Any change Any change change or more change or more change or more Number of states with trends: 32 32 0 0 51 51 Rate improved (+) 26 24 —b —b 48 36 Rate worsened (-) 6 5 —b —b 3 2 Little/no change in rate 0 3 —b —b 0 13 a A positive or negative value indicates that current performance is better or worse. b Data not updated; data presented here are used for both past and current ranking. * Data could not be updated for this state. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 88 E x H I B I T A 1 2 (continued) Avoidable Hospital Use and Costs: Dimension Ranking and Performance on Indicators (continued) Note: Change in rate is expressed such Indicator Performance that a positive value Hospital Care Intensity indicates performance Percent Long-Stay Percent Short-Stay Nursing Index, Chronically Ill has improved and Medicare 30-Day Hospital Nursing Home Residents Home Residents with Percent Home Health Patients Medicare Beneficiaries in a negative value Readmission Rates with Hospital Admission Readmission Within 30 Days with Hospital Admission Last Two Years of Life indicates performance Avoidable Hospital Use has worsened. Actual Percent Actual Percent Actual Percent Actual Percent Actual Percent Current Change in Change in Current Change in Change in Current Change in Change in Current Change in Change in Current Change in Change in State Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea Rate Ratea Ratea United States 18.4 -0.4 -2.2% 19.9 -1.5 -8.2% 21.2 -2.1 -11.0% 31.9 -3.9 -13.9% 1.020 -0.001 -0.1% Alabama 17.5 0.7 3.8% 22.6 -2.8 -14.1% 21.8 -0.2 -0.9% 31.1 2.6 7.7% 0.978 0.029 2.9% Alaska 17.3 -0.3 -1.8% * * * * * * 24.1 0.2 0.8% 0.703 0.028 3.8% Arizona 18.7 -0.1 -0.5% 8.5 0.7 7.6% 22.9 -4.9 -27.3% 26.8 -6.8 -34.0% 0.886 -0.033 -3.9% Arkansas 21.3 0.3 1.4% 27.2 -2.1 -8.4% 25.7 -1.4 -5.8% 35.6 -0.1 -0.3% 1.000 0.057 5.4% California 17.1 -0.4 -2.4% 18.1 -3.3 -22.3% 20.6 -2.3 -12.6% 26.5 -4.6 -21.0% 1.158 -0.014 -1.2% Colorado 15.7 1.1 6.6% 10.8 -0.5 -4.9% 17.5 -1.5 -9.4% 28.6 -6.1 -27.1% 0.743 -0.006 -0.8% Connecticut 17.3 -0.9 -5.5% 16.8 -3.1 -22.7% 19.0 -2.2 -13.1% 35.9 -5.5 -18.1% 0.964 -0.029 -3.1% Delaware 20.6 -3.0 -17.1% 19.6 -2.0 -11.4% 23.0 -4.4 -23.7% 27.3 -1.0 -3.8% 1.091 0.080 6.8% District of Columbia 22.7 -2.5 -12.3% * * * * * * 26.0 1.3 4.8% 1.255 0.000 0.0% Florida 17.2 -0.1 -0.6% 22.7 -2.1 -10.2% 21.9 -2.1 -10.6% 24.9 -3.7 -17.4% 1.177 -0.010 -0.9% Georgia 17.7 0.2 1.1% 20.9 -0.3 -1.5% 21.9 -1.7 -8.4% 28.2 0.7 2.4% 0.903 0.004 0.4% Hawaii 16.6 -1.4 -9.2% * * * * * * 23.5 1.2 4.9% 1.051 0.134 11.3% Idaho 14.3 0.2 1.4% 12.2 0.0 0.0% 14.6 -0.3 -2.1% 24.7 -1.9 -8.3% 0.535 0.012 2.2% Illinois 20.3 -0.7 -3.6% 24.8 -3.5 -16.4% 23.8 -3.5 -17.2% 32.9 -4.9 -17.5% 1.142 -0.048 -4.4% Indiana 18.3 -1.4 -8.3% 19.9 -1.0 -5.3% 18.9 -1.5 -8.6% 34.4 -4.1 -13.5% 0.854 -0.025 -3.0% Iowa 15.9 -1.5 -10.4% 16.7 -0.4 -2.5% 18.3 -2.4 -15.1% 36.1 -4.6 -14.6% 0.753 -0.008 -1.1% Kansas 19.2 -0.9 -4.9% 20.1 -1.8 -9.8% 20.9 -2.1 -11.1% 28.7 -1.5 -5.5% 0.886 -0.018 -2.1% Kentucky 20.2 -0.9 -4.7% 25.7 -1.7 -7.1% 22.6 -2.0 -9.7% 34.2 1.9 5.3% 1.008 0.003 0.3% Louisiana 21.3 1.3 5.8% 31.4 -1.9 -6.5% 26.8 -0.3 -1.1% 43.3 3.1 6.7% 1.206 0.038 3.1% Maine 16.7 0.3 1.8% 14.2 -3.4 -31.4% 17.3 -2.6 -17.6% 27.7 -0.6 -2.2% 0.723 -0.005 -0.7% Maryland 19.9 -1.4 -7.5% 19.4 -2.6 -15.4% 24.0 -2.7 -12.6% 24.6 -2.0 -8.8% 0.981 -0.004 -0.4% Massachusetts 19.4 -0.1 -0.5% 14.8 0.6 3.9% 19.5 -1.6 -8.9% 34.1 -5.1 -17.6% 0.962 0.010 1.0% Michigan 20.0 -1.7 -9.3% 19.6 -3.4 -20.9% 23.3 -5.0 -27.3% 28.8 -3.0 -11.7% 1.015 -0.018 -1.8% Minnesota 16.6 -1.6 -10.7% 6.9 5.5 44.4% 17.6 -2.0 -12.8% 32.7 -5.8 -21.6% 0.697 0.027 3.7% Mississippi 17.7 0.2 1.1% 29.9 -1.1 -3.8% 21.1 0.7 3.2% 40.1 -0.1 -0.2% 1.069 0.108 9.2% Missouri 18.3 -0.1 -0.5% 21.6 -1.4 -6.9% 21.7 -1.9 -9.6% 26.9 -0.3 -1.1% 0.977 -0.003 -0.3% Montana 15.0 0.4 2.6% 13.9 -1.5 -12.1% 15.5 -2.3 -17.4% 24.2 -1.3 -5.7% 0.646 -0.031 -5.0% Nebraska 14.2 0.1 0.7% 16.5 -1.3 -8.6% 16.6 -0.8 -5.1% 25.3 -0.5 -2.0% 0.819 -0.028 -3.5% Nevada 22.6 -0.1 -0.4% 15.1 0.1 0.7% 23.2 -3.4 -17.1% 27.8 -3.2 -13.0% 1.192 0.034 2.8% New Hampshire 17.3 -1.5 -9.5% 11.8 -0.9 -8.3% 16.5 -2.1 -14.6% 30.4 -0.6 -2.0% 0.737 0.007 0.9% New Jersey 19.0 -0.5 -2.7% 26.7 -1.6 -6.4% 25.0 -0.9 -3.7% 27.7 -1.2 -4.5% 1.548 0.016 1.0% New Mexico 16.2 0.3 1.8% 13.5 -1.3 -10.6% 18.2 -1.2 -7.0% 29.0 -4.7 -19.3% 0.642 0.034 5.0% New York 18.3 -0.3 -1.7% 20.6 -3.3 -19.1% 22.5 -4.1 -22.3% 39.3 -8.9 -29.2% 1.322 0.016 1.2% North Carolina 16.8 -1.0 -6.3% 19.7 -1.3 -7.1% 19.5 -1.8 -10.2% 30.9 -3.6 -13.2% 0.837 0.023 2.7% North Dakota 15.3 0.9 5.6% 14.3 -0.8 -5.9% 16.9 -0.5 -3.0% 22.1 1.7 7.2% 0.639 0.032 4.8% Ohio 19.8 -1.1 -5.9% 19.1 -0.4 -2.1% 21.3 -1.9 -9.8% 37.3 -8.0 -27.3% 0.974 -0.049 -5.3% Oklahoma 20.9 -0.7 -3.5% 25.0 0.7 2.7% 24.6 -1.8 -7.9% 39.2 -2.1 -5.7% 0.958 0.011 1.1% Oregon 12.9 0.5 3.7% 8.9 -1.7 -23.7% 17.0 -2.4 -16.5% 22.1 -2.0 -9.9% 0.544 -0.013 -2.5% Pennsylvania 19.6 0.1 0.5% 18.3 -0.5 -2.8% 20.9 -0.5 -2.5% 25.2 0.8 3.1% 1.141 0.003 0.3% Rhode Island 18.5 -1.8 -10.7% 13.1 1.5 10.3% 22.0 -3.7 -20.2% 30.1 -3.7 -14.0% 0.907 0.064 6.6% South Carolina 16.8 -0.1 -0.6% 19.9 -1.4 -7.6% 19.4 -1.3 -7.2% 31.7 -2.9 -10.1% 1.012 -0.036 -3.7% South Dakota 14.1 4.8 25.4% 15.2 0.6 3.8% 15.2 1.5 9.0% 22.6 -0.1 -0.4% 0.748 0.047 5.9% Tennessee 18.8 0.0 0.0% 24.2 -1.1 -4.8% 22.4 -2.3 -11.4% 33.4 1.2 3.5% 1.012 0.038 3.6% Texas 19.4 0.2 1.0% 24.8 -0.8 -3.3% 23.1 -0.4 -1.8% 37.7 -3.2 -9.3% 1.127 -0.010 -0.9% Utah 13.6 1.3 8.7% 9.7 -0.2 -2.1% 13.2 -0.8 -6.4% 21.2 -2.9 -15.9% 0.509 -0.014 -2.8% Vermont 14.4 -1.5 -11.6% 11.3 -1.9 -20.2% 14.3 0.1 0.7% 30.0 0.2 0.7% 0.652 -0.052 -8.7% Virginia 17.3 -0.8 -4.8% 20.3 -2.4 -13.4% 20.8 -3.1 -17.5% 29.1 -1.6 -5.8% 0.940 0.018 1.9% Washington 16.2 -0.4 -2.5% 12.7 -2.3 -22.2% 16.9 -1.3 -8.4% 21.9 -0.9 -4.3% 0.593 -0.007 -1.2% West Virginia 21.9 -3.1 -16.5% 23.0 -0.1 -0.4% 22.6 -1.2 -5.6% 28.8 6.1 17.5% 0.983 -0.002 -0.2% Wisconsin 16.2 -1.1 -7.3% 13.8 -1.1 -8.7% 17.7 -3.2 -21.9% 27.7 -0.9 -3.4% 0.719 0.013 1.8% Wyoming 16.0 0.0 0.0% 14.2 0.7 4.7% 15.7 0.0 0.0% 25.4 0.2 0.8% 0.599 0.011 1.8% 5% 5% 5% 5% 5% Any change Any change Any change Any change Any change change or more change or more change or more change or more change or more Number of states with trends: 51 51 48 48 48 48 51 51 51 51 Rate improved (+) 17 5 8 3 3 1 13 5 27 7 Rate worsened (-) 32 16 39 29 44 37 38 27 23 3 Little/no change in rate 2 30 1 16 1 10 0 19 1 41 a A positive or negative value indicates that current performance is better or worse. b Data not updated; data presented here are used for both past and current ranking. * Data could not be updated for this state. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 89 E x H I B I T A 1 2 (continued) Avoidable Hospital Use and Costs: Dimension Ranking and Performance on Indicators (continued) Note: Change in rate Indicator Performance is expressed such that a positive value indicates performance Total Single Health has improved and Insurance Premium per Total Medicare a negative value Enrolled Employee Reimbursements per Enrollee indicates performance Annual Costs has worsened. Actual Percent Actual Percent Current Change in Change in Current Change in Change in State Rate Rate a Ratea Rate Ratea Ratea United States 4,386 -681 -18.4% 8,304 -1,336 -19.2% Alabama 4,139 -725 -21.2% 7,833 -996 -14.6% Alaska 5,293 -914 -20.9% 7,700 -981 -14.6% Arizona 4,214 -776 -22.6% 7,841 -1,399 -21.7% Arkansas 3,923 -673 -20.7% 7,470 -1,346 -22.0% California 4,280 -746 -21.1% 8,899 -1,063 -13.6% Colorado 4,303 -619 -16.8% 7,496 -1,071 -16.7% Connecticut 4,740 -876 -22.7% 8,972 -1,173 -15.0% Delaware 4,733 -903 -23.6% 7,646 -635 -9.1% District of Columbia 4,890 -672 -15.9% 7,551 -835 -12.4% Florida 4,517 -710 -18.6% 9,379 -1,748 -22.9% Georgia 4,160 -825 -24.7% 7,451 -1,149 -18.2% Hawaii 3,831 -712 -22.8% 5,311 -532 -11.1% Idaho 4,104 -675 -19.7% 6,411 -1,036 -19.3% Illinois 4,643 -875 -23.2% 8,457 -1,515 -21.8% Indiana 4,495 -909 -25.3% 7,698 -1,568 -25.6% Iowa 4,146 -585 -16.4% 6,572 -1,463 -28.6% Kansas 4,197 -486 -13.1% 7,421 -1,049 -16.5% Kentucky 4,009 -467 -13.2% 8,260 -1,553 -23.2% Louisiana 4,055 -570 -16.4% 9,401 -1,364 -17.0% Maine 4,910 -794 -19.3% 6,952 -1,115 -19.1% Maryland 4,360 -639 -17.2% 8,987 -1,324 -17.3% Massachusetts 4,836 -695 -16.8% 9,379 -1,182 -14.4% Michigan 4,388 -470 -12.0% 8,785 -1,551 -21.4% Minnesota 4,432 -623 -16.4% 6,600 -1,061 -19.2% Mississippi 4,124 -517 -14.3% 7,855 -985 -14.3% Missouri 4,124 -565 -15.9% 7,709 -1,431 -22.8% Montana 4,355 -675 -18.3% 6,340 -901 -16.6% Nebraska 4,392 -667 -17.9% 6,922 -1,281 -22.7% Nevada 3,927 -53 -1.4% 8,714 -1,157 -15.3% New Hampshire 5,247 -1,163 -28.5% 7,814 -1,694 -27.7% New Jersey 4,798 -916 -23.6% 9,551 -986 -11.5% New Mexico 4,074 -673 -19.8% 6,803 -1,382 -25.5% New York 4,638 -780 -20.2% 9,564 -1,362 -16.6% North Carolina 4,460 -909 -25.6% 7,492 -1,294 -20.9% North Dakota 3,830 -488 -14.6% 6,108 -1,128 -22.6% Ohio 4,089 -307 -8.1% 8,249 -1,451 -21.3% Oklahoma 4,072 -428 -11.7% 8,642 -1,628 -23.2% Oregon 4,384 -678 -18.3% 6,122 -953 -18.4% Pennsylvania 4,499 -828 -22.6% 8,215 -955 -13.2% Rhode Island 4,930 -562 -12.9% 8,557 -1,383 -19.3% South Carolina 4,477 -704 -18.7% 7,608 -1,297 -20.6% South Dakota 4,233 -784 -22.7% 6,253 -995 -18.9% Tennessee 4,276 -642 -17.7% 8,149 -1,429 -21.3% Texas 4,205 -424 -11.2% 9,361 -1,809 -24.0% Utah 4,197 -1,163 -38.3% 6,859 -1,216 -21.5% Vermont 4,900 -826 -20.3% 7,284 -1,438 -24.6% Virginia 4,202 -337 -8.7% 6,856 -996 -17.0% Washington 4,404 -796 -22.1% 7,110 -1,284 -22.0% West Virginia 4,892 -1,200 -32.5% 7,828 -1,520 -24.1% Wisconsin 4,777 -850 -21.6% 6,978 -1,300 -22.9% Wyoming 4,622 -861 -22.9% 6,591 -1,040 -18.7% 5% 5% Any change Any change change or more change or more Number of states with trends: 51 51 51 51 Rate improved (+) 0 0 0 0 Rate worsened (-) 51 50 51 51 Little/no change in rate 0 1 0 0 a A positive or negative value indicates that current performance is better or worse. b Data not updated; data presented here are used for both past and current ranking. * Data could not be updated for this state. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 90 EXHIBIT A13 Healthy Lives: Dimension and Indicator Ranking State Rank are are Top Quartile hC hC ese ese Second Quartile alt alt ies ies Ob Ob He He s s Third Quartile at h at h vit vit or or to to c ti c ti s s ht ht De De Bottom Quartile at h at h le le nA nA e e e ig e ig ab ab er er ok ok De De it y it y en en di di er w er w nc nc Sm Sm s s at h at h er er 2009 Ranking Revised 2007 Rankinga ite ite Ca Ca t al t al Am Am Ov Ov nc nc ho ho im im or or De De t al t al lit y lit y Ca Ca sW sW ren ren tM tM sL sL ec ec de de st st r ta r ta ult ult ult ult lor lor an an ild ild ici ici ea ea Mo Mo Ad Ad Ad Ad Inf Inf Ch Ch Co Co Su Su Br Br RANK S TAT E RANK S TAT E 1 Minnesota 1 Hawaii 2 Hawaii 2 California 3 Connecticut 3 Utah 4 Utah 4 Colorado 5 California 5 Minnesota 6 Massachusetts 6 Connecticut 7 Iowa 7 Washington 8 Vermont 8 Iowa 8 Wisconsin 8 Massachusetts 10 North Dakota 10 Vermont 10 Colorado 11 New Hampshire 12 Idaho 12 Idaho 13 Washington 13 Nebraska 14 New Hampshire 14 North Dakota 14 Nebraska 15 Arizona 16 Wyoming 16 Rhode Island 17 New York 17 Wyoming 18 Oregon 18 New Mexico 19 New Jersey 19 South Dakota 20 Rhode Island 20 Oregon 21 Arizona 21 Wisconsin 21 Texas 22 Texas 23 Maine 23 Maine 24 Maryland 24 New Jersey 25 Montana 25 New York 26 Florida 26 Alaska 27 Alaska 27 Kansas 28 Virginia 28 Montana 29 New Mexico 29 Virginia 30 South Dakota 30 Florida 31 Kansas 30 Maryland 32 Illinois 32 Delaware 33 Pennsylvania 33 Illinois 34 Delaware 34 Nevada 35 Michigan 35 Michigan 36 Indiana 35 Georgia 37 Georgia 37 North Carolina 38 District of Columbia 38 Pennsylvania 39 Nevada 39 Ohio 40 North Carolina 40 Indiana 41 Missouri 41 District of Columbia 42 Ohio 42 Alabama 43 South Carolina 43 Missouri 44 Oklahoma 44 Oklahoma 45 Kentucky 45 South Carolina 46 Louisiana 46 Tennessee 47 Alabama 46 Arkansas 48 Arkansas 48 Louisiana 49 Tennessee 49 West Virginia 50 West Virginia 50 Mississippi 51 Mississippi 51 Kentucky a Some state rates have been revised to match methodology used in the 2009 edition. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 91 ExHIBIT A14 Healthy Lives: Dimension Ranking and Performance on Indicators Note: Change in rate is expressed such that a positive value indicates performance Indicator Performance has improved and a negative value indicates performance has worsened. Mortality Amenable to Health Care, Infant Mortality, Breast Cancer Deaths Deaths per 100,000 Population Deaths per 1,000 Live Births per 100,000 Female Population Current Past Actual Percent Actual Percent Actual Percent Dimension Dimension Current Change in Change in Current Change in Change in Current Change in Change in State Rank Rank Rate Rate a Ratea Rate Rate a Ratea Rate Rate a Ratea United States 95.6 9.5 9.0% 6.9 0.1 1.4% 24.1 1.5 5.9% Alabama 47 42 116.6 7.9 6.3% 9.5 -0.4 -4.4% 27.4 -1.9 -7.5% Alaska 27 26 76.8 6.9 8.2% 5.9 -0.3 -5.4% 17.7 2.8 13.7% Arizona 21 15 87.5 5.3 5.7% 6.8 -0.4 -6.3% 21.1 1.5 6.6% Arkansas 48 46 121.1 -0.7 -0.6% 7.8 0.6 7.1% 24.3 1.1 4.3% California 5 2 86.3 6.3 6.8% 5.3 0.1 1.9% 22.6 1.3 5.4% Colorado 10 4 72.4 5.5 7.1% 6.4 -0.4 -6.7% 22.5 0.2 0.9% Connecticut 3 6 77.2 14.2 15.5% 5.9 0.6 9.2% 23.4 1.9 7.5% Delaware 34 32 96.7 13.4 12.2% 9.0 -0.4 -4.7% 23.6 -0.1 -0.4% District of Columbia 38 41 158.3 15.9 9.1% 13.7 -2.7 -24.5% 29.8 4.3 12.6% Florida 26 30 90.7 4.8 5.0% 7.2 0.3 4.0% 22.5 1.2 5.1% Georgia 37 35 114.4 7.5 6.2% 8.1 0.9 10.0% 23.7 1.5 6.0% Hawaii 2 1 79.8 11.4 12.5% 6.6 0.8 10.8% 19.0 -2.8 -17.3% Idaho 12 12 74.3 8.6 10.4% 6.0 0.1 1.6% 19.2 6.0 23.8% Illinois 32 33 101.3 17.4 14.7% 7.4 0.0 0.0% 25.6 1.5 5.5% Indiana 36 40 101.2 10.4 9.3% 8.0 -0.2 -2.6% 22.8 2.9 11.3% Iowa 7 8 79.1 14.1 15.1% 5.4 -0.1 -1.9% 21.1 3.7 14.9% Kansas 31 27 84.9 8.2 8.8% 7.4 -0.2 -2.8% 23.8 2.6 9.8% Kentucky 45 51 110.1 10.2 8.5% 6.7 0.5 6.9% 23.8 3.6 13.1% Louisiana 46 48 137.2 1.0 0.7% 9.8 0.2 2.0% 29.3 0.4 1.3% Maine 23 23 77.8 8.1 9.4% 6.9 -2.6 -60.5% 22.2 1.8 7.5% Maryland 24 30 107.5 8.4 7.2% 7.3 0.3 3.9% 25.7 3.7 12.6% Massachusetts 6 8 78.0 9.3 10.7% 5.1 -0.3 -6.3% 23.2 3.0 11.5% Michigan 35 35 102.1 12.7 11.1% 7.9 0.2 2.5% 23.8 3.0 11.2% Minnesota 1 5 63.9 11.8 15.6% 5.1 0.2 3.8% 22.4 0.3 1.3% Mississippi 51 50 142.0 9.4 6.2% 11.5 -1.5 -15.0% 26.0 0.6 2.3% Missouri 41 43 103.0 9.9 8.8% 7.5 1.0 11.8% 28.0 -1.9 -7.3% Montana 25 28 73.2 10.3 12.3% 7.3 0.2 2.7% 23.3 4.2 15.3% Nebraska 14 13 72.5 12.0 14.2% 5.7 1.3 18.6% 23.9 0.3 1.2% Nevada 39 34 112.5 0.7 0.6% 5.7 0.4 6.6% 24.1 1.8 6.9% New Hampshire 14 11 72.6 11.2 13.4% 5.3 -0.3 -6.0% 23.2 1.0 4.1% New Jersey 19 24 89.9 15.9 15.0% 5.2 0.5 8.8% 26.7 1.6 5.7% New Mexico 29 18 83.1 2.1 2.5% 6.2 -0.1 -1.6% 22.3 -0.4 -1.8% New York 17 25 93.0 15.3 14.1% 5.8 0.2 3.3% 24.0 2.1 8.0% North Carolina 40 37 108.0 11.6 9.7% 8.8 -0.7 -8.6% 25.4 1.0 3.8% North Dakota 10 14 72.9 13.3 15.4% 6.0 0.3 4.8% 22.3 3.7 14.2% Ohio 42 39 105.6 10.1 8.7% 8.2 -0.3 -3.8% 26.3 1.7 6.1% Oklahoma 44 44 115.4 4.5 3.8% 8.0 0.2 2.4% 25.1 1.9 7.0% Oregon 18 20 75.2 6.7 8.2% 6.0 -0.3 -5.3% 21.9 2.9 11.7% Pennsylvania 33 38 98.8 11.5 10.4% 7.3 0.3 3.9% 24.8 3.1 11.1% Rhode Island 20 16 85.9 6.9 7.4% 6.5 0.6 8.5% 24.5 -1.1 -4.7% South Carolina 43 45 115.5 13.2 10.3% 9.5 -0.2 -2.2% 26.2 0.7 2.6% South Dakota 30 19 80.8 12.8 13.7% 7.0 -0.3 -4.5% 23.7 0.2 0.8% Tennessee 49 46 118.1 6.8 5.4% 8.8 0.5 5.4% 26.7 -0.9 -3.5% Texas 21 22 100.4 3.2 3.1% 6.5 -0.2 -3.2% 23.1 1.2 4.9% Utah 4 3 64.1 7.5 10.5% 4.5 1.1 19.6% 24.1 -0.2 -0.8% Vermont 8 10 68.0 12.7 15.7% 6.5 -2.1 -47.7% 20.4 1.0 4.7% Virginia 28 29 96.1 9.5 9.0% 7.5 -0.1 -1.4% 25.8 1.1 4.1% Washington 13 7 74.2 7.8 9.5% 5.1 0.7 12.1% 23.1 0.7 2.9% West Virginia 50 49 111.7 10.7 8.7% 8.2 0.7 7.9% 27.1 -4.3 -18.9% Wisconsin 8 21 77.7 14.2 15.5% 6.5 0.3 4.4% 22.6 2.0 8.1% Wyoming 16 17 74.8 6.9 8.4% 6.6 0.1 1.5% 21.0 -1.6 -8.2% 5% 5% 5% Any change Any change Any change change or more change or more change or more Number of states with trends: 51 51 51 51 51 51 Rate improved (+) 50 45 28 14 41 27 Rate worsened (-) 1 0 22 11 10 5 Little/no change in rate 0 6 1 26 0 19 a A positive or negative value indicates that current performance is better or worse. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 92 E x H I B I T A 1 4 (continued) Healthy Lives: Dimension Ranking and Performance on Indicators (continued) Note: Change in rate is expressed such Indicator Performance that a positive value Percent Nonelderly Adults indicates performance (Ages 18–64) Limited in Percent Children has improved and Colorectal Cancer Deaths Suicide Deaths Activities Because of Physical, Ages 10–17 Who Are a negative value per 100,000 Population per 100,000 Population Mental, or Emotional Problems Percent Adults Who Smoke Overweight or Obese indicates performance Actual Percent Actual Percent Actual Percent Actual Percent Actual Percent has worsened. Current Change in Change in Current Change in Change in Current Change in Change in Current Change in Change in Current Change in Change in State Rate Rate a Rate a Rate Rate a Ratea Rate Rate a Rate a Rate Rate a Ratea Rate Ratea Ratea United States 17.5 2.2 11.2% 10.9 -0.1 -0.9% 16.9 -1.1 -7.0% 19.4 2.0 9.4% 31.7 -1.2 -3.9% Alabama 18.8 -0.1 -0.5% 11.5 -0.1 -0.9% 21.6 -2.6 -13.7% 22.7 2.4 9.6% 36.1 -1.5 -4.3% Alaska 15.0 2.9 16.2% 20.2 0.2 1.0% 18.9 -2.0 -11.8% 22.9 2.5 9.8% 33.9 -3.2 -10.4% Arizona 15.5 1.1 6.6% 16.2 -0.7 -4.5% 15.6 0.3 1.9% 18.9 0.7 3.6% 30.5 -0.8 -2.7% Arkansas 18.9 1.7 8.3% 14.2 -0.6 -4.4% 20.5 -1.6 -8.4% 23.0 2.1 8.4% 37.5 -4.7 -14.3% California 15.8 1.3 7.6% 9.1 0.7 7.1% 15.5 -2.2 -16.6% 14.6 1.2 7.6% 30.5 -0.5 -1.7% Colorado 16.6 1.5 8.3% 17.3 -1.2 -7.5% 15.1 -0.6 -4.1% 18.2 1.0 5.2% 27.2 -5.3 -24.2% Connecticut 15.1 4.2 21.8% 8.1 -0.6 -8.0% 14.7 -0.7 -5.0% 16.1 2.2 12.0% 25.7 1.6 5.9% Delaware 17.9 2.5 12.3% 9.6 1.8 15.8% 18.9 -4.5 -31.1% 20.3 2.9 12.5% 33.1 2.4 6.8% District of Columbia 21.1 3.5 14.2% 5.5 0.7 11.3% 14.1 -1.3 -10.1% 17.4 4.0 18.7% 35.3 4.2 10.6% Florida 16.4 1.8 9.9% 12.6 0.3 2.3% 16.7 0.8 4.6% 20.1 1.9 8.7% 33.2 -0.8 -2.5% Georgia 17.8 1.6 8.2% 10.5 1.1 9.5% 17.3 -1.7 -10.8% 19.5 1.7 8.0% 37.3 -5.6 -17.7% Hawaii 14.5 2.8 16.2% 8.3 1.8 17.8% 12.9 -2.7 -26.4% 17.2 0.0 0.0% 28.5 -1.7 -6.3% Idaho 15.5 -0.1 -0.6% 16.2 0.0 0.0% 17.7 -0.3 -1.7% 18.0 0.2 1.1% 27.5 -1.9 -7.4% Illinois 18.5 3.5 15.9% 8.5 -0.5 -6.3% 14.6 -2.1 -16.8% 20.3 2.5 11.0% 34.9 -3.7 -11.9% Indiana 19.4 2.0 9.3% 11.9 0.1 0.8% 16.4 -1.0 -6.5% 24.0 1.4 5.5% 29.9 3.0 9.1% Iowa 18.2 1.8 9.0% 10.9 0.8 6.8% 14.1 -1.1 -8.4% 20.6 0.6 2.8% 26.5 -1.0 -3.9% Kansas 18.6 1.6 7.9% 13.1 -0.4 -3.1% 15.8 -2.1 -15.3% 18.9 1.2 6.0% 31.1 -1.0 -3.3% Kentucky 21.0 2.9 12.1% 13.3 0.2 1.5% 23.2 -1.8 -8.4% 28.3 0.7 2.4% 37.2 1.0 2.6% Louisiana 20.1 3.2 13.7% 11.1 -0.7 -6.7% 17.0 -1.7 -11.2% 23.0 2.0 8.0% 35.9 -0.3 -0.8% Maine 17.2 3.7 17.7% 12.3 -2.4 -24.2% 19.6 -0.9 -4.8% 20.5 1.8 8.1% 28.2 1.8 6.0% Maryland 18.7 2.1 10.1% 8.4 0.5 5.6% 15.4 -0.1 -0.7% 17.3 2.5 12.6% 28.8 1.1 3.7% Massachusetts 17.6 3.7 17.4% 7.2 -0.7 -10.8% 16.1 -1.6 -11.0% 17.0 1.7 9.1% 30.1 -1.2 -4.2% Michigan 18.0 1.3 6.7% 10.8 -0.7 -6.9% 18.9 -0.9 -5.0% 21.7 3.0 12.2% 30.6 -1.9 -6.6% Minnesota 14.8 3.7 20.0% 10.3 -0.6 -6.2% 15.0 3.4 18.4% 17.4 3.5 16.8% 23.1 0.8 3.3% Mississippi 20.2 2.3 10.2% 12.6 -0.7 -5.9% 20.0 0.2 1.0% 24.4 0.5 2.0% 44.5 -7.9 -21.6% Missouri 18.3 3.0 14.1% 12.4 -0.6 -5.1% 20.3 -2.9 -16.7% 23.8 1.8 7.0% 30.9 0.1 0.3% Montana 17.7 0.6 3.3% 21.5 -2.2 -11.4% 18.8 -2.0 -12.0% 19.2 1.0 5.0% 25.6 1.7 6.2% Nebraska 18.5 3.2 14.7% 10.8 -0.7 -6.9% 14.6 -0.6 -4.3% 19.3 1.5 7.2% 31.4 -5.1 -19.4% Nevada 18.5 2.7 12.7% 20.1 0.0 0.0% 17.2 -1.9 -12.4% 21.8 2.4 9.9% 34.2 -7.6 -28.6% New Hampshire 17.6 -0.1 -0.6% 11.8 0.1 0.8% 17.9 -1.2 -7.2% 19.0 2.4 11.2% 29.5 -2.2 -8.1% New Jersey 18.6 2.9 13.5% 6.0 0.7 10.4% 14.5 -0.8 -5.8% 17.5 1.5 7.9% 31.0 0.5 1.6% New Mexico 16.3 1.9 10.4% 17.7 1.0 5.3% 18.0 -1.8 -11.1% 20.4 0.7 3.3% 32.7 -3.8 -13.1% New York 16.8 3.7 18.0% 6.0 -0.1 -1.7% 15.5 0.6 3.7% 18.5 2.2 10.6% 32.9 -2.0 -6.5% North Carolina 17.3 2.3 11.7% 11.5 -0.2 -1.8% 17.5 -2.5 -16.6% 22.4 1.5 6.3% 33.5 0.5 1.5% North Dakota 18.5 1.5 7.5% 13.7 -1.3 -10.5% 12.0 0.1 0.8% 20.2 -0.1 -0.5% 25.7 1.2 4.5% Ohio 18.8 2.3 10.9% 11.4 -2.1 -22.6% 19.5 -4.3 -28.3% 22.7 2.8 11.0% 33.3 -2.8 -9.2% Oklahoma 19.5 0.5 2.5% 14.7 -1.1 -8.1% 21.9 -3.4 -18.4% 25.4 0.2 0.8% 29.5 -1.3 -4.6% Oregon 16.9 1.0 5.6% 14.8 1.4 8.6% 21.4 -1.1 -5.4% 17.6 2.8 13.7% 24.3 2.1 8.0% Pennsylvania 18.8 2.5 11.7% 11.1 -0.6 -5.7% 16.5 -0.3 -1.9% 21.1 2.9 12.1% 29.6 -0.3 -1.0% Rhode Island 16.8 4.3 20.4% 6.3 1.3 17.1% 17.1 -2.4 -16.2% 18.1 3.7 17.0% 30.2 -3.2 -11.9% South Carolina 18.8 1.2 6.0% 11.8 -0.3 -2.6% 18.0 -1.6 -9.7% 22.0 2.9 11.7% 33.8 2.3 6.4% South Dakota 19.5 -0.5 -2.6% 15.3 -1.8 -13.3% 14.9 -0.4 -2.8% 20.0 1.4 6.5% 28.4 -2.6 -10.1% Tennessee 19.4 0.5 2.5% 14.0 -1.2 -9.4% 18.0 -1.0 -5.9% 23.4 2.5 9.7% 36.5 -1.2 -3.4% Texas 16.8 2.0 10.6% 10.9 0.3 2.7% 16.4 -1.3 -8.6% 18.6 2.6 12.3% 32.3 0.1 0.3% Utah 13.3 2.0 13.1% 15.1 0.5 3.2% 15.3 0.4 2.5% 10.7 0.4 3.6% 23.1 -2.3 -11.1% Vermont 17.6 4.7 21.1% 12.2 0.7 5.4% 17.2 -0.6 -3.6% 17.7 2.0 10.1% 26.8 -1.2 -4.7% Virginia 17.2 3.0 14.9% 11.2 -0.3 -2.8% 15.4 0.0 0.0% 18.8 2.5 11.7% 30.9 -0.4 -1.3% Washington 15.3 1.6 9.5% 12.7 0.2 1.6% 20.8 -1.0 -5.0% 16.9 2.4 12.4% 29.5 -4.4 -17.5% West Virginia 19.8 3.3 14.3% 13.2 0.9 6.4% 24.0 -0.2 -0.8% 26.3 0.8 3.0% 35.6 0.9 2.5% Wisconsin 16.3 2.1 11.4% 11.5 0.1 0.9% 14.2 0.6 4.1% 20.1 1.8 8.2% 27.9 1.5 5.1% Wyoming 13.8 5.4 28.1% 17.2 4.6 21.1% 16.6 -1.1 -7.1% 21.8 1.3 5.6% 25.7 -2.9 -12.7% 5% 5% 5% 5% 5% Any change Any change Any change Any change Any change change or more change or more change or more change or more change or more Number of states with trends: 51 51 51 51 51 51 51 51 51 51 Rate improved (+) 47 44 23 14 8 1 49 40 18 9 Rate worsened (-) 4 0 26 18 42 33 1 0 33 20 Little/no change in rate 0 7 2 19 1 17 1 11 0 22 a A positive or negative value indicates that current performance is better or worse. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 93 ExHIBIT A15 Mortality Amenable to Health Care by Race, Deaths per 100,000 population, 2004–05 Note: Change in rate is expressed such that a positive value indicates performance Total White Black has improved and a negative value Actual Percent Actual Percent Actual Percent indicates performance has worsened. Change in Change in Change in Change in Change in Change in State 2004–05 Rate a Ratea Rank 2004–05 Rate a Ratea Rank 2004–05 Rate a Ratea Rank United States 95.6 9.5 9.0% 86.1 9.7 10.1% 183.0 11.4 5.9% Alabama 116.6 7.9 6.3% 46 96.7 6.6 6.4% 43 189.4 12.3 6.1% 30 Alaska 76.8 6.9 8.2% 13 67.5 9.8 12.7% 4 112.5 58.1 34.1% 5 Arizona 87.5 5.3 5.7% 25 85.2 5.1 5.6% 30 146.0 7.2 4.7% 14 Arkansas 121.1 -0.7 -0.6% 48 108.4 -2.0 -1.9% 48 218.7 12.3 5.3% 41 California 86.3 6.3 6.8% 24 84.0 6.6 7.3% 28 174.7 5.4 3.0% 23 Colorado 72.4 5.5 7.1% 4 71.0 5.3 6.9% 9 127.7 8.7 6.4% 8 Connecticut 77.2 14.2 15.5% 14 72.3 14.5 16.7% 11 136.6 13.6 9.1% 11 Delaware 96.7 13.4 12.2% 30 86.8 9.0 9.4% 32 147.7 42.0 22.1% 15 District of Columbia 158.3 15.9 9.1% 51 56.4 12.7 18.4% 1 219.9 10.2 4.4% 42 Florida 90.7 4.8 5.0% 27 80.9 5.2 6.0% 25 166.6 8.5 4.9% 17 Georgia 114.4 7.5 6.2% 43 91.5 7.9 7.9% 37 190.1 9.1 4.6% 31 Hawaii 79.8 11.4 12.5% 19 72.5 2.4 3.2% 12 67.8 5.4 7.4% 1 Idaho 74.3 8.6 10.4% 10 74.2 8.6 10.4% 15 * * * * Illinois 101.3 17.4 14.7% 34 86.2 17.0 16.5% 31 208.8 20.7 9.0% 39 Indiana 101.2 10.4 9.3% 33 94.8 11.2 10.6% 41 186.2 5.2 2.7% 27 Iowa 79.1 14.1 15.1% 18 78.1 13.7 14.9% 21 144.3 52.3 26.6% 13 Kansas 84.9 8.2 8.8% 22 80.4 9.5 10.6% 22 170.3 -4.8 -2.9% 20 Kentucky 110.1 10.2 8.5% 40 106.1 9.6 8.3% 46 176.5 24.6 12.2% 25 Louisiana 137.2 1.0 0.7% 49 105.6 3.0 2.8% 45 221.0 -3.3 -1.5% 44 Maine 77.8 8.1 9.4% 16 77.3 8.2 9.6% 20 * * * * Maryland 107.5 8.4 7.2% 38 86.8 8.5 8.9% 32 172.0 11.8 6.4% 22 Massachusetts 78.0 9.3 10.7% 17 76.6 9.7 11.2% 19 125.3 2.1 1.6% 7 Michigan 102.1 12.7 11.1% 35 87.3 12.7 12.7% 34 207.8 13.9 6.3% 38 Minnesota 63.9 11.8 15.6% 1 61.1 12.9 17.4% 2 128.5 -2.9 -2.3% 9 Mississippi 142.0 9.4 6.2% 50 107.7 11.1 9.3% 47 220.9 8.6 3.7% 43 Missouri 103.0 9.9 8.8% 36 93.7 9.2 8.9% 40 196.0 16.6 7.8% 36 Montana 73.2 10.3 12.3% 8 70.3 9.9 12.3% 8 * * * * Nebraska 72.5 12.0 14.2% 5 68.9 12.3 15.1% 6 166.6 6.9 4.0% 17 Nevada 112.5 0.7 0.6% 42 109.1 3.3 2.9% 50 190.6 -23.4 -14.0% 32 New Hampshire 72.6 11.2 13.4% 6 72.6 11.6 13.8% 13 85.8 * * 2 New Jersey 89.9 15.9 15.0% 26 80.8 16.5 17.0% 23 168.8 17.8 9.5% 19 New Mexico 83.1 2.1 2.5% 21 82.0 2.4 2.8% 26 107.9 38.4 26.2% 4 New York 93.0 15.3 14.1% 28 84.8 16.3 16.1% 29 148.8 15.3 9.3% 16 North Carolina 108.0 11.6 9.7% 39 89.2 10.2 10.3% 35 186.4 22.8 10.9% 28 North Dakota 72.9 13.3 15.4% 7 69.6 14.2 16.9% 7 * * * * Ohio 105.6 10.1 8.7% 37 95.5 11.1 10.4% 42 197.3 2.8 1.4% 37 Oklahoma 115.4 4.5 3.8% 44 108.9 7.4 6.4% 49 195.8 2.1 1.1% 35 Oregon 75.2 6.7 8.2% 12 74.7 6.6 8.1% 17 135.2 24.7 15.4% 10 Pennsylvania 98.8 11.5 10.4% 31 90.2 11.6 11.4% 36 193.0 13.2 6.4% 33 Rhode Island 85.9 6.9 7.4% 23 83.7 7.6 8.3% 27 141.0 -7.0 -5.2% 12 South Carolina 115.5 13.2 10.3% 45 91.8 11.4 11.0% 39 187.6 18.8 9.1% 29 South Dakota 80.8 12.8 13.7% 20 74.4 12.8 14.7% 16 * * * * Tennessee 118.1 6.8 5.4% 47 103.7 5.7 5.2% 44 212.9 17.5 7.6% 40 Texas 100.4 3.2 3.1% 32 91.7 4.0 4.2% 38 193.7 -2.5 -1.3% 34 Utah 64.1 7.5 10.5% 2 63.9 7.1 10.0% 3 86.3 24.9 22.4% 3 Vermont 68.0 12.7 15.7% 3 68.6 12.6 15.5% 5 * * * * Virginia 96.1 9.5 9.0% 29 80.8 9.3 10.3% 23 175.6 12.6 6.7% 24 Washington 74.2 7.8 9.5% 9 73.4 7.9 9.7% 14 118.6 27.1 18.6% 6 West Virginia 111.7 10.7 8.7% 41 110.6 10.5 8.7% 51 171.1 13.1 7.1% 21 Wisconsin 77.7 14.2 15.5% 15 72.0 15.8 18.0% 10 180.3 -2.2 -1.2% 26 Wyoming 74.8 6.9 8.4% 11 74.7 5.1 6.4% 17 * * * * a A positive or negative value indicates that current performance is better or worse. * Data is missing because there were fewer than 20 deaths. DATA: Analysis of 2001–02 and 2004–05 CDC Multiple Cause-of-Death data files using Nolte and McKee methodology, BMJ 2003. SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 94 ExHIBIT A16 State Demographics: Income and Health Status Mortality Amenable to Percent of Population Health Care, Deaths per with Incomes Less than 200% 100,000 Population of Federal Poverty Level Median Household Income 2004–05 Rank 2006–07 Rank 2005–07 Rank United States 95.6 35.8 $49,901 Alabama 116.6 46 39.2 38 40,232 45 Alaska 76.8 13 28.2 6 60,124 6 Arizona 87.5 25 40.2 42 47,750 29 Arkansas 121.1 48 43.8 50 39,279 49 California 86.3 24 39.1 37 55,864 13 Colorado 72.4 4 29.0 7 57,333 10 Connecticut 77.2 14 26.6 2 62,893 5 Delaware 96.7 30 31.5 17 54,310 14 District of Columbia 158.3 51 39.2 38 NA NA Florida 90.7 27 36.2 35 46,142 35 Georgia 114.4 43 36.1 34 49,387 23 Hawaii 79.8 19 33.4 24 63,164 4 Idaho 74.3 10 34.8 30 47,876 28 Illinois 101.3 34 33.4 24 51,320 18 Indiana 101.2 33 32.7 22 46,407 33 Iowa 79.1 18 29.4 10 49,262 24 Kansas 84.9 22 32.9 23 46,659 32 Kentucky 110.1 40 41.0 45 39,678 47 Louisiana 137.2 49 43.0 49 39,461 48 Maine 77.8 16 32.0 19 47,160 31 Maryland 107.5 38 27.1 3 65,124 2 Massachusetts 78.0 17 31.1 14 58,286 7 Michigan 102.1 35 33.6 27 49,394 22 Minnesota 63.9 1 27.7 4 57,815 8 Mississippi 142.0 50 48.1 51 35,971 50 Missouri 103.0 36 35.2 31 45,834 36 Montana 73.2 8 35.7 33 41,852 42 Nebraska 72.5 5 29.5 11 49,861 20 Nevada 112.5 42 33.9 29 53,008 16 New Hampshire 72.6 6 22.2 1 63,942 3 New Jersey 89.9 26 28.1 5 65,933 1 New Mexico 83.1 21 41.7 46 42,295 41 New York 93.0 28 37.5 36 49,546 21 North Carolina 108.0 39 39.4 40 43,035 39 North Dakota 72.9 7 31.9 18 44,743 38 Ohio 105.6 37 33.7 28 47,750 29 Oklahoma 115.4 44 41.7 46 41,046 44 Oregon 75.2 12 35.3 32 48,521 26 Pennsylvania 98.8 31 32.5 21 49,155 25 Rhode Island 85.9 23 31.2 15 54,009 15 South Carolina 115.5 45 39.4 40 42,561 40 South Dakota 80.8 20 31.3 16 46,321 34 Tennessee 118.1 47 40.4 43 41,632 43 Texas 100.4 32 42.3 48 44,861 37 Utah 64.1 2 33.5 26 55,974 12 Vermont 68.0 3 29.2 9 51,566 17 Virginia 96.1 29 30.3 13 57,679 9 Washington 74.2 9 29.0 7 56,049 11 West Virginia 111.7 41 40.5 44 40,103 46 Wisconsin 77.7 15 29.9 12 50,619 19 Wyoming 74.8 11 32.2 20 48,205 27 NA = data not available. DATA: Mortality amenable—2004–05 CDC Multiple Cause-of-Death data using Nolte and McKee methodology (Nolte and McKee, BMJ 2003); Income less than 200% of poverty—Kaiser statehealthfacts.org (2007–08 CPS ASEC Supplement); Median Income—Kaiser statehealthfacts.org (2006–08 CPS ASEC Supplement); Cancer—Kaiser statehealthfacts.org (National Cancer Institute); Adults Overweight/Obesity, Asthma, Diabetes—Kaiser statehealthfacts.org (BRFSS) SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 95 E x H I B I T A 1 6 (continued) State Demographics: Income and Health Status (continued) Percent of Adults Percent of Adults Who Have Ever Been Age-Adjusted Cancer Incidence Who are Overweight Adult Self-Reported Current Told by a Doctor that Rate per 100,000 Population or Obese Asthma Prevalence Rate They Have Diabetes 2004 Rank 2008 Rank 2007 Rank 2008 Rank United States 458.2 63.0 8.2 8.2 Alabama 450.5 20 67.9 49 8.8 34 11.2 49 Alaska 454.6 24 65.4 38 7.8 13 6.6 7 Arizona 383.3 1 61.1 12 8.7 29 7.7 19 Arkansas 446.6 15 65.6 41 7.0 5 9.5 38 California 435.0 6 61.3 13 7.5 8 8.5 31 Colorado 432.1 5 55.3 2 7.8 13 6.0 2 Connecticut 477.3 36 59.7 7 9.3 40 6.8 8 Delaware 487.5 41 63.6 30 7.8 13 8.2 25 District of Columbia 455.0 25 55.0 1 9.4 44 7.9 22 Florida 448.1 17 60.1 10 6.2 1 9.5 38 Georgia 461.9 29 64.6 35 7.6 10 9.8 42 Hawaii 423.6 4 57.3 3 8.0 17 8.2 25 Idaho 451.1 22 62.1 20 8.7 29 7.0 11 Illinois 473.0 34 63.2 25 8.3 23 8.3 28 Indiana 446.2 14 63.5 28 8.8 34 9.5 38 Iowa 467.0 31 64.2 33 7.0 5 7.0 11 Kansas 467.9 32 65.5 40 8.4 26 8.1 24 Kentucky 500.2 47 66.6 46 9.0 37 9.8 42 Louisiana 489.1 42 63.6 30 6.3 2 10.6 48 Maine 526.1 50 61.7 17 10.3 51 8.2 25 Maryland NA NA 63.3 26 8.3 23 8.6 33 Massachusetts 501.7 48 58.0 4 9.9 48 7.1 13 Michigan 478.2 38 64.6 35 9.5 45 9.0 35 Minnesota 490.5 43 62.7 23 7.7 11 5.9 1 Mississippi 448.0 16 67.4 48 6.6 3 11.3 50 Missouri 448.8 18 65.4 38 8.5 27 9.1 36 Montana 444.8 12 61.6 16 9.3 40 6.4 4 Nebraska 462.1 30 64.1 32 8.1 19 7.7 19 Nevada 451.2 23 62.6 22 6.9 4 8.5 31 New Hampshire 498.0 46 63.0 24 10.2 50 7.2 14 New Jersey 496.4 45 62.0 19 8.3 23 8.4 29 New Mexico 409.0 2 59.9 8 8.7 29 7.8 21 New York 478.6 39 60.2 11 8.7 29 8.4 29 North Carolina 450.5 20 65.7 42 7.8 13 9.3 37 North Dakota 445.2 13 67.3 47 7.7 11 7.5 18 Ohio 449.0 19 63.3 26 8.9 36 9.9 44 Oklahoma 457.1 27 66.4 45 8.6 28 10.1 45 Oregon 473.8 35 61.5 14 9.7 47 6.9 9 Pennsylvania 487.3 40 64.2 33 9.3 40 8.8 34 Rhode Island 506.9 49 59.9 8 9.9 48 7.4 17 South Carolina 456.9 26 65.8 43 7.5 8 10.1 45 South Dakota 457.7 28 64.9 37 7.1 7 6.5 6 Tennessee 435.6 7 67.9 49 8.7 29 10.3 47 Texas 442.2 9 66.1 44 8.2 22 9.7 41 Utah 411.2 3 58.1 5 8.1 19 6.1 3 Vermont 477.3 36 58.4 6 9.6 46 6.4 4 Virginia 436.2 8 61.5 14 8.0 17 7.9 22 Washington 492.5 44 61.8 18 9.3 40 6.9 9 West Virginia 471.1 33 68.7 51 9.0 37 11.9 51 Wisconsin 443.1 10 63.5 28 9.2 39 7.2 14 Wyoming 444.6 11 62.1 20 8.1 19 7.3 16 NA = data not available. DATA: Mortality amenable—2004–05 CDC Multiple Cause-of-Death data using Nolte and McKee methodology (Nolte and McKee, BMJ 2003); Income less than 200% of poverty—Kaiser statehealthfacts.org (2007–08 CPS ASEC Supplement); Median Income—Kaiser statehealthfacts.org (2006–08 CPS ASEC Supplement); Cancer—Kaiser statehealthfacts.org (National Cancer Institute); Adults Overweight/Obesity, Asthma, Diabetes—Kaiser statehealthfacts.org (BRFSS) SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 96 ExHIBIT A17 State Demographics: Race and Ethnic Groups, U.S. (2007) and States (2006–07) White Black Hispanic Other United States 66.0 12.2 15.4 6.7 Alabama 67.6 26.2 3.2 3.0 Alaska 70.9 3.3 4.0 21.8 Arizona 58.2 3.5 31.4 6.9 Arkansas 75.7 15.8 5.3 3.2 California 43.1 6.2 36.6 14.1 Colorado 72.8 3.8 19.5 3.9 Connecticut 75.1 9.1 11.7 4.1 Delaware 68.0 19.9 7.2 5.0 District of Columbia 32.9 54.6 8.7 3.7 Florida 60.7 14.7 21.5 3.2 Georgia 58.6 29.4 7.7 4.3 Hawaii 17.8 2.0 6.9 73.3 Idaho 86.9 0.4 9.5 3.2 Illinois 65.4 15.0 13.5 6.1 Indiana 84.9 8.4 4.8 1.8 Iowa 89.0 2.3 5.2 3.4 Kansas 81.4 5.5 8.0 5.1 Kentucky 88.4 7.3 2.2 2.1 Louisiana 64.5 31.3 2.7 1.5 Maine 95.2 0.9 0.8 3.1 Maryland 57.7 28.7 7.4 6.3 Massachusetts 80.1 6.4 6.8 6.7 Michigan 78.0 13.9 3.7 4.4 Minnesota 85.5 4.2 4.5 5.9 Mississippi 57.6 37.1 2.4 2.9 Missouri 82.0 11.2 3.0 3.8 Montana 89.0 0.5 2.3 8.2 Nebraska 83.8 4.3 7.8 4.1 Nevada 58.6 7.4 23.7 10.3 New Hampshire 93.3 1.0 2.5 3.2 New Jersey 60.3 13.3 16.5 10.0 New Mexico 44.0 2.2 40.7 13.0 New York 59.9 14.5 17.0 8.6 North Carolina 67.4 21.1 6.6 4.9 North Dakota 86.4 0.8 2.1 10.7 Ohio 82.7 11.5 2.9 2.9 Oklahoma 69.4 7.6 5.9 17.1 Oregon 80.9 1.8 9.5 7.8 Pennsylvania 83.2 10.0 4.1 2.7 Rhode Island 79.5 5.3 10.6 4.6 South Carolina 65.2 28.6 3.6 2.6 South Dakota 89.9 0.7 2.6 6.8 Tennessee 77.0 16.6 3.8 2.7 Texas 46.6 11.3 37.5 4.6 Utah 81.8 0.9 12.2 5.1 Vermont 94.8 0.7 0.9 3.5 Virginia 66.8 19.1 6.9 7.2 Washington 76.5 3.3 8.6 11.6 West Virginia 94.7 3.2 0.4 1.7 Wisconsin 84.9 5.6 5.6 3.9 Wyoming 88.3 0.9 7.7 3.1 DATA: Kaiser statehealthfacts.org (2007–08 CPS ASEC Supplement) SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 97 Appendix B.1. State Scorecard Data Years and Databases Past Year Current Year Database ACCESS 1 Nonelderly adults (ages 18–64) insured 2004–2005 2007–2008 CPS ASEC (2006–2007 by income and race/ethnicity) 2 Children (ages 0–17) insured 2004–2005 2007–2008 CPS ASEC (2006–2007 by income and race/ethnicity) 3 At-risk adults visited a doctor for routine checkup in the past two years 1999–2000 2006–2007 BRFSS 4 Adults without a time in the past year when they needed 2003–2004 2006–2007 BRFSS to see a doctor but could not because of cost Past Year Current Year Database P R E V E N T I O N & T R E AT M E N T 5 Adults age 50 and older received recommended screening and preventive care 2004 2006 BRFSS 6 Adult diabetics received recommended preventive care 2003–2004 2006–2007 BRFSS 7 Children ages 19–35 months received all recommended doses of 2005 2007 NIS five key vaccines 8 Children with both a medical and dental preventive care visit in the past year 2003 2007 NSCH 9 Children who received needed mental health care in the past year 2003 2007 NSCH 10 Hospitalized patients received recommended care for 2004 2007 CMS Hospital heart attack, heart failure, and pneumonia Compare 11 Surgical patients received appropriate care to prevent complications 2004 2007 CMS Hospital Compare 12 Home health patients who get better at walking or moving around 2005 2007 OASIS 13 Adults with a usual source of care 2003–2004 2006–2007 BRFSS 14 Children with a medical home 2003 2007 NSCH 15 Heart failure patients given written instructions at discharge 2004 2007 CMS Hospital Compare 16 Medicare patients whose health care provider always listens, explains, 2003 2007 CAHPS shows respect, and spends enough time with them 17 Medicare patients giving a best rating for health care received in the past year 2003 2007 CAHPS 18 High-risk nursing home residents with pressure sores 2004 2007 MDS 19 Long-stay nursing home residents who were physically restrained 2004 2007 MDS 20 Long-stay nursing home residents who have moderate to severe pain 2004 2007 MDS Past Year Current Year Database P O T E N T I A L LY AV O I D A B L E U S E O F H O S P I TA L S & C O S T S O F C A R E 21 Hospital admissions for pediatric asthma per 100,000 children 2003 2005 HCUP 22 Adult asthmatics with an emergency room or urgent care visit in the past year 2001–2004 Not Updated BRFSS 23 Medicare hospital admissions for ambulatory care sensitive conditions 2003–2004 2006–2007 Medicare per 100,000 beneficiaries SAF 5% Data from CCW 24 Medicare 30-day hospital readmissions as a percent of admissions 2003–2004 2006–2007 Medicare SAF 5% Data from CCW 25 Long-stay nursing home residents with a hospital admission 2000 2006 MEDPAR, MDS 26 Short-stay nursing home residents with a hospital readmission within 30 days 2000 2006 MEDPAR, MDS 27 Home health patients with a hospital admission 2004 2007 OASIS 28 Hospital Care Intensity Index, based on inpatient days and inpatient visits 2003 2005 Dartmouth Atlas among chronically ill Medicare beneficiaries in last two years of life 29 Total single premium per enrolled employee at private-sector establishments 2004 2008 MEPS that offer health insurance 30 Total Medicare (Parts A & B) reimbursements per enrollee 2003 2006 Dartmouth Atlas 98 Appendix B.1. State Scorecard Data Years and Databases (continued) Past Year Current Year Database H E A LT H Y L I V E S 31 Mortality amenable to health care, deaths per 100,000 population 2001–2002 2004–2005 CDC Mortality Data 32 Infant mortality, deaths per 1,000 live births 2002 2005 NVSS-I (2000–2002 by (2002–2004 by race/ethnicity) race/ethnicity) 33 Breast cancer deaths per 100,000 female population 2002 2005 NVSS-M 34 Colorectal cancer deaths per 100,000 population 2002 2005 NVSS-M 35 Suicide deaths per 100,000 population 2003 2005 NVSS-M 36 Nonelderly adults (ages 18–64) limited in any activities 2003–2004 2006–2007 BRFSS because of physical, mental, or emotional problems 37 Adults who smoke 2003–2004 2006–2007 BRFSS 38 Children ages 10–17 who are overweight or obese 2003 2007 NSCH Definition of Databases BRFSS = Behavioral Risk Factor Surveillance System CAHPS = Consumer Assessment of Healthcare Providers and Systems CCW = Chronic Condition Warehouse CDC = Centers for Disease Control and Prevention CPS ASEC = Annual Social and Economic Supplement to the Current Population Survey HCUP = Healthcare Cost and Utilization Project MDS = Nursing Home Minimum Data Set MEDPAR = Medicare Provider Analysis and Review MEPS = Medical Expenditure Panel Survey NIS = National Immunization Survey NSCH = National Survey of Children’s Health OASIS = Outcome and Assessment Information Set NVSS-I = National Vital Statistics System, Linked Birth and Infant Death Data NVSS-M = National Vital Statistics System, Mortality Data SAF = Standard Analytical Files 99 Appendix B.2. State Scorecard Indicator Descriptions 1 Nonelderly adults (ages 18–64) insured: Authors’ analysis of Annual 10 Hospitalized patients received recommended care for heart Social and Economic Supplement to the Current Population Survey attack, heart failure, and pneumonia: Proportion of cases where (CPS ASEC) using the CPS Table Creator online at http://www.census. a hospital provided the recommended process of care for patients gov/hhes/www/cpstc/cps_table_creator.html (U.S. Census Bureau, with acute myocardial infarction (heart attack), heart failure, and 2008, 2009) and Employee Benefit Research Institute analysis of CPS pneumonia. Data for 2004 is a composite of 10 clinical services: five ASEC (U.S. Census Bureau, 2005, 2006, 2007, 2008). clinical services for heart attack (aspirin at arrival and at discharge; beta-blocker at arrival and at discharge; and angiotensin-converting 2 Children (ages 0–17) insured: Authors’ analysis of CPS ASEC enzyme (ACE) inhibitor for left ventricular systolic dysfunction), two using the CPS Table Creator online at http://www.census.gov/ for heart failure (assessment of left ventricular function and the use hhes/www/cpstc/cps_table_creator.html (U.S. Census Bureau, of an ACE inhibitor for left ventricular dysfunction), and three for 2008, 2009) and Employee Benefit Research Institute analysis pneumonia (initial antibiotic received within four hours of hospital of CPS ASEC (U.S. Census Bureau, 2005, 2006, 2007, 2008). arrival; pneumococcal vaccination; and assessment of oxygenation). 3 At-risk adults visited a doctor for routine checkup in the past Data for 2007 is a composite of 19 clinical services, including the two years: Percent of adults age 50 and older, or in fair or poor original 10 from 2004 and nine additional services: three for heart health, or ever told they have diabetes or pre-diabetes, acute attack (smoking cessation advice/counseling; thrombolytic agent myocardial infarction, heart disease, stroke, or asthma who visited received within 30 minutes of hospital arrival; and PCI within 90 a doctor in the past two years. Rutgers Center for State Health minutes of hospital arrival); two for heart failure (smoking cessation Policy (CSHP) analysis of Behavioral Risk Factor Surveillance advice/counseling, discharge instructions); and four for pneumonia System (BRFSS) (NCCDPHP, BRFSS 1999, 2000, 2006, 2007). (smoking cessation advice/counseling; blood cultures performed in the emergency department prior to initial antibiotic received 4 Adults without a time in the past year when they needed in hospital; appropriate initial antibiotic selection; and influenza to see a doctor but could not because of cost: Rutgers CSHP vaccination). IPRO analysis of CMS Hospital Compare data (DHHS n.d.). analysis of BRFSS (NCCDPHP, BRFSS 2003, 2004, 2006, 2007). 11 Surgical patients received appropriate care to prevent 5 Adults age 50 and older received recommended screening and complications: Proportion of cases where a hospital provided preventive care: Percent of adults age 50 and older who have recommended processes of care for surgical patients to prevent received: sigmoidoscopy or colonoscopy in the last ten years or a complications. Data for 2004 is a composite of two clinical fecal occult blood test in the last two years; a mammogram in the last services: prophylactic antibiotics within 1 hour prior to surgery two years (women only); a pap smear in the last three years (women and discontinued within 24 hours after surgery. Data for 2007 only); and a flu shot in the past year and a pneumonia vaccine ever is a composite of five clinical services, original two from 2004 (age 65 and older only). Rutgers CSHP analysis of BRFSS (NCCDPHP, and three additional services: prophylactic antibiotic selection BRFSS 2002, 2004, 2006). 2002 data were imputed for one state. for surgical patients; surgery patients with recommended venous thromboembolism prophylaxis ordered and received 6 Adult diabetics received recommended preventive care: within 24 hours prior to surgery to 24 hours after surgery. Percent of adults age 18 and older who were told by a doctor IPRO analysis of CMS Hospital Compare data (DHHS n.d.). that they had diabetes and have received: hemoglobin A1c test, dilated eye exam, and foot exam in the past year. Rutgers CSHP 12 Home health patients who get better at walking or moving analysis of BRFSS (NCCDPHP, BRFSS 2003, 2004, 2006, 2007). around: This indicator is new to the 2009 edition. Data from Outcome and Assessment Information Set (CMS, OASIS n.d.), reported in 7 Children ages 19–35 months received all recommended doses the National Healthcare Quality Report (AHRQ 2006, 2008). of five key vaccines: Percent of children ages 19 to 35 months who have received at least 4 doses of diphtheria-tetanus-acellular 13 Adults with a usual source of care: Percent of adults age pertussis (DTaP), at least 3 doses of polio, at least 1 dose of measles- 18 and older who have one (or more) person they think of as mumps-rubella (MMR), at least 3 doses of Haemophilus influenzae their personal doctor or health care provider. Rutgers CSHP B (Hib), and at least 3 doses of hepatitis B antigens. Data from analysis of BRFSS (NCCDPHP, BRFSS 2003, 2004, 2006, 2007). the National Immunization Survey (NCHS, NIS 2005, 2007). 14 Children with a medical home: Percent of children ages 0–17 who 8 Children with both a medical and dental preventive care visit received health care that meets criteria of having a medical home. in the past year: Percent of children ages 0–17 with one or more Data for 2003 and 2007 are not comparable because of changes medical and dental preventive care visits during the past 12 months. in survey design. For 2003, the indicator measured whether the Data for 2003 and 2007 are not comparable because of changes child had at least one preventive medical care visit in the past year; in survey design. The 2003 survey asked whether the child saw a had a personal doctor/nurse who: provided family-centered care, dentist for any routine preventive dental care including checkups, telephone advice and urgent care when needed, and follow-up screenings, and sealants. For 2007, the survey asked how many times after specialty care when needed; and had no problems getting the child saw a dentist for preventive dental care such as checkups specialty care when needed. For 2007, the indicator measured and dental cleanings. Both surveys asked how many times the child whether the child had a personal doctor or nurse, had a usual source saw a doctor, nurse, or other health care provider for preventive for sick and well care, received family-centered care from all health medical care such as a physical exam or well-child checkup. For more care providers, did not have problems getting needed referrals, information, see www.nschdata.org. Data from National Survey and received effective care coordination when needed. For more of Children’s Health (NSCH), assembled by Child and Adolescent information, see www.nschdata.org. Data from National Survey Health Measurement Initiative (CAHMI) (CAHMI 2005, 2009). of Children’s Health, assembled by CAHMI (CAHMI 2005, 2009). 9 Children who received needed mental health care in the 15 Heart failure patients given written instructions at past year: Percent of children with an emotional, behavioral, or discharge: Percent of heart failure patients with documentation developmental problem who needed treatment or counseling and that they or their caregivers were given written instructions who received some type of mental health care during the past 12 or other educational materials at discharge. IPRO analysis months. There were slight modifications in survey design. The 2003 of CMS Hospital Compare data (DHHS n.d.). survey measured children ages 1–17 and asked whether they received mental health care or counseling. For 2007, the survey measured children ages 2–17 and asked whether they received treatment or counseling from a mental health professional (as defined). For more information, see www.nschdata.org. Data from National Survey of Children’s Health, assembled by CAHMI (CAHMI 2005, 2009). 100 Appendix B.2. State Scorecard Indicator Descriptions (continued) 16 Medicare patients whose health provider always listens, explains, 24 Medicare 30-day hospital readmissions as a percent of shows respect, and spends enough time with them: Percent admissions: Fee-for-service Medicare beneficiaries age 65 and of Medicare fee-for-service patients who had a doctor’s office or older with initial admissions due to one of 31 select conditions clinic visit in the last 12 months whose health providers always (see list) who are readmitted within 30 days following discharge listened carefully, explained things clearly, respected what they for the initial admission. Analysis of Medicare Standard Analytical had to say, and spent enough time with them. Time trends should Files (SAF) 5% Data from Chronic Condition Warehouse (CCW) be interpreted with caution due to change in survey methodology. by G. Anderson and R. Herbert at Johns Hopkins Bloomberg Data from National Consumer Assessment of Healthcare Providers School of Public Health (CMS, SAF 2003, 2004, 2006, 2007). and Systems (CAHPS) Benchmarking Database (AHRQ, CAHPS n.d.), 1.Abnormal heartbeat reported in National Healthcare Quality Report (AHRQ 2005, 2008). 2.Chronic obstructive pulmonary disease (COPD) 17 Medicare patients giving a best rating for health care received 3.Congestive heart failure in the past year: Percent of Medicare fee-for-service patients who 4.Diabetes with amputation had a doctor’s office or clinic visit in the last 12 months who gave 5.Diabetes - medical management a best rating for health care they received. Time trends should be 6.Kidney failure interpreted with caution due to change in survey methodology. Data 7.Kidney and urinary tract infections from National CAHPS Benchmarking Database (AHRQ, CAHPS n.d.), 8.Pneumonia - aspiration reported in National Healthcare Quality Report (AHRQ 2005, 2008). 9.Pneumonia - infectious 10.Respiratory failure with mechanical ventilation 18 High-risk nursing home residents with pressure sores: Percent of 11.Respiratory failure without mechanical ventilation long-stay nursing home residents impaired in bed mobility or transfer, 12.Stomach and intestinal bleeding comatose, or malnourished who have pressure sores (Stages 1–4) on 13.Stroke - hemorrhagic target assessment. Data from CMS Minimum Data Set (CMS, MDS n.d.), 14.Stroke - non-hemorrhagic reported in National Healthcare Quality Report (AHRQ 2005, 2008). 15.Abdominal aortic aneurysm repair 19 Long-stay nursing home residents who were physically 16.Gallbladder removal - laparoscopic restrained: Percent of long-stay nursing home residents who 17.Gallbladder removal - open were physically restrained daily on target assessment. Data 18.Hip fracture - surgical repair from CMS Minimum Data Set (CMS, MDS n.d.), reported in 19.Hysterectomy - vaginal National Healthcare Quality Report (AHRQ 2005, 2008). 20.Removal of blockage of neck vessels 21.Bronchitis & asthma, complicated DRG096 20 Long-stay nursing home residents who have moderate to 22.Bronchitis & asthma, uncomplicated DRG097 severe pain: This indicator is new to the 2009 edition. Percent of 23.Hypotension & fainting, complicated DRG141 long-stay nursing home residents with moderate pain at least daily 24.Chest pain DRG143 or horrible or excruciating pain at any frequency on the target 25.Cirrhosis & alcoholic hepatitis DRG202 assessment. Data from CMS Minimum Data Set (CMS, MDS n.d.), 26.Noncancerous pancreatic disorders DRG204 reported in National Healthcare Quality Report (AHRQ 2005, 2008). 27.Liver disease except cancer, cirrhosis, alcoholic hepatitis, complicated DRG205 21 Hospital admissions for pediatric asthma per 100,000 children 28.Medical back problems DRG243 (ages 2–17): Excludes patients with cystic fibrosis or anomalies of the 29.Surgery for infectious or parasitic disease DRG415 respiratory system, and transfers from other institutions. Data from 30.Infection after surgery or trauma DRG418 Healthcare Cost and Utilization Project State Inpatient Databases; 31.Vascular operations except heart, complicated DRG478 not all states participate in HCUP. Estimates for total U.S. are from the Nationwide Inpatient Sample (AHRQ, HCUP-SID 2003, 2005). 25 Long-stay nursing home residents with a hospital admission: Reported in National Healthcare Quality Report (AHRQ 2007, 2008). Percent of long-stay residents (residing in a nursing home for at least 90 consecutive days) who were ever hospitalized within six 22 Adult asthmatics with an emergency room or urgent care visit in months of baseline assessment. Analysis of Medicare enrollment the past year: Percent of adults age 18 and older who were told by a data and MEDPAR File by V. Mor, Brown University, under a doctor that they had asthma and had an emergency room or urgent grant funded by the National Institute of Aging (#PO1AG027296, care visit in the past 12 months. Updated data for this indicator were Shaping Long-Term Care in America). unavailable, so data from the same year are used for both past and current ranking. Data represent the average for up to four years of 26 Short-stay nursing home residents with a hospital readmission data to improve state sample sizes; most states did not have data for within 30 days: Percent of newly admitted nursing home residents this measure for all four years. Data differ from 2007 edition where (never been in a facility before) who are rehospitalized within 30 only the most current year of data for each state was used. Rutgers days of being discharged to nursing home. Analysis of Medicare CSHP analysis of BRFSS (NCCDPHP, BRFSS 2001, 2002, 2003, 2004). enrollment data and MEDPAR File by V. Mor, Brown University, under a grant funded by the National Institute of Aging (#PO1AG027296, 23 Medicare hospital admissions for ambulatory care sensitive Shaping Long-Term Care in America). conditions per 100,000 beneficiaries: Hospital admissions of fee-for-service Medicare beneficiaries age 65 and older for one of 27 Home health patients with a hospital admission: Percent of 11 ambulatory care sensitive conditions (AHRQ Indicators): short- acute care hospitalization for home health episodes. Data from term diabetes complications, long-term diabetes complications, Outcome and Assessment Information Set (CMS, OASIS n.d.), lower extremity amputation among patients with diabetes, asthma, reported in National Healthcare Quality Report (AHRQ 2005, 2008). chronic obstructive pulmonary disease, hypertension, congestive heart failure, angina (without a procedure), dehydration, bacterial pneumonia, and urinary tract infection. Results calculated using AHRQ Prevention Quality Indicators, Version 3.0. Analysis of Medicare Standard Analytical Files (SAF) 5% Data from Chronic Condition Warehouse (CCW) by G. Anderson and R. Herbert at Johns Hopkins Bloomberg School of Public Health (CMS, SAF 2003, 2004, 2006, 2007). 101 Appendix B.2. State Scorecard Indicator Descriptions (continued) 28 Hospital Care Intensity Index, based on inpatient days and 32 Infant mortality, deaths per 1,000 live births: Data from National inpatient physician visits among chronically ill Medicare Vital Statistics System (NVSS)–Linked Birth and Infant Death Data beneficiaries in last two years of life: This indicator is new to the (NCHS, NVSS n.d.), reported in National Healthcare Quality Report 2009 edition. The Hospital Care Intensity Index is an age-sex-race- (NCHS 2005, 2007) and Health, United States (NCHS 2005, 2007). illness standardized ratio of patient days and visits for chronically ill Medicare patients. It is calculated as the simple average of two 33 Breast cancer deaths per 100,000 female population: ratios: the number of days spent in the hospital to the national Data from NVSS–Mortality Data (NCHS, NVSS n.d.), reported average and the number of inpatient physician visits to the national in National Healthcare Quality Report (AHRQ 2005, 2008). average. The national average was set to 1.0 for the base year 2001 34 Colorectal cancer deaths per 100,000 population: Data (not shown) so that ratios in subsequent years reflect the national from NVSS–Mortality Data (NCHS, NVSS n.d.), reported in trend in this composite measure of inpatient utilization. Data from National Healthcare Quality Report (AHRQ 2005, 2008). Dartmouth Atlas of Health Care (Dartmouth Atlas Project 2003, 2005). 35 Suicide deaths per 100,000 population: This indicator is new to 29 Total single premium per enrolled employee at private- the 2009 edition. Data from NVSS–Mortality Data (NCHS, NVSS n.d.), sector establishments that offer health insurance: reported in National Healthcare Quality Report (AHRQ 2005, 2008). Data from Medical Expenditure Panel Survey–Insurance Component (AHRQ, MEPS-IC 2004, 2008). 36 Nonelderly adults (ages 18–64) limited in any activities because of physical, mental, or emotional problems: Rutgers CSHP 30 Total Medicare (Parts A & B) reimbursements per enrollee: Total analysis of BRFSS (NCCDPHP, BRFSS 2003, 2004, 2006, 2007). Medicare fee-for-service reimbursements include payments for both Part A and Part B (exclude capitated payments). Reimbursement 37 Adults who smoke: This indicator is new to the 2009 edition. Percent rates were indirectly adjusted for sex, race, and age. Data from of adults age 18 and older who ever smoked 100+ cigarettes (five Dartmouth Atlas of Health Care (Dartmouth Atlas Project 2003, 2006). packs) and currently smoke every day or some days. Rutgers CSHP analysis of BRFSS (NCCDPHP, BRFSS 2003, 2004, 2006, 2007). 31 Mortality amenable to health care, deaths per 100,000 population: Number of deaths before age 75 per 100,000 38 Children ages 10–17 who are overweight or obese: This population that resulted from causes considered at least partially indicator is new to the 2009 edition. Overweight is defined as an treatable or preventable with timely and appropriate medical age- and gender-specific body mass index (BMI-for-age) between care (see list), as described in Nolte and McKee (Nolte and McKee, the 85th and 94th percentile of the CDC growth charts. Obese is BMJ 2003). Analysis conducted by K. Hempstead at Rutgers defined as a BMI-for-age at or above the 95th percentile. BMI was CSHP using mortality data from CDC Multiple Cause-of-Death calculated based on parent-reported height and weight. For more file and U.S. Census Bureau population data (NCHS, MCD n.d.). information, see www.nschdata.org. Data from National Survey of Children’s Health, assembled by CAHMI (CAHMI 2005, 2009). Causes of death Age Intestinal infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-14 Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Other infections (diphtheria, tetanus, septicaemia, poliomyelitis) . . . . . . . . 0-74 Whooping cough. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-14 Measles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-14 Malignant neoplasm of colon and rectum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Malignant neoplasm of skin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Malignant neoplasm of breast. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Malignant neoplasm of cervix uteri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Malignant neoplasm of cervix uteri and body of uterus. . . . . . . . . . . . . . . . . . . . . . 0-44 Malignant neoplasm of testis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Hodgkin’s disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Leukemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-44 Diseases of the thyroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-49 Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Chronic rheumatic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Hypertensive disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Cerebrovascular disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 All respiratory diseases (excluding pneumonia and influenza). . . . . . . . . . . . . 1-14 Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Peptic ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Appendicitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Abdominal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Cholelithiasis and cholecystitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Nephritis and nephrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Benign prostatic hyperplasia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Maternal death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All Congenital cardiovascular anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-74 Perinatal deaths, all causes, excluding stillbirths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All Misadventures to patients during surgical and medical care . . . . . . . . . . . . . . . . . . All Ischaemic heart disease: 50% of mortality rates included . . . . . . . . . . . . . . . . . . . 0-74 102 Appendix B.3. Complete References for Data Sources AHRQ (Agency for Healthcare Research and Quality). (2008). Dartmouth Atlas Project (2003, 2005, 2006). Dartmouth National Healthcare Quality Report, 2008. AHRQ Pub. No. 09-0001. Atlas of Health Care. Hanover, NH: Dartmouth Institute Rockville, Md.: U.S. Department of Health and Human Services. for Health Policy and Clinical Practice (formerly the Center for the Evaluative Clinical Sciences), Dartmouth AHRQ (Agency for Healthcare Research and Quality). (2007). Medical School. http://www.dartmouthatlas.org. National Healthcare Quality Report, 2007. AHRQ Pub. No. 08-0040. Rockville, Md.: U.S. Department of Health and Human Services. DHHS, Hospital Compare (U.S. Department of Health and Human Services, Hospital Compare Database). (n.d.). Washington, D.C.: AHRQ (Agency for Healthcare Research and Quality). (2006). http://www.hospitalcompare.hhs.gov/Download/DownloadDB.asp. National Healthcare Quality Report, 2006. AHRQ Pub. No. 07-0013. Rockville, Md.: U.S. Department of Health and Human Services. NCCDPHP, BRFSS (National Center for Chronic Disease Prevention and Health Promotion, Behavioral Risk Factor Surveillance System). AHRQ (Agency for Healthcare Research and Quality). (2005). (1999, 2000, 2002, 2003, 2004, 2006, 2007). Atlanta, Ga.: Centers for National Healthcare Quality Report, 2005. AHRQ Pub. No. 06-0018. Disease Control. http://www.cdc.gov/brfss/. Rockville, Md.: U.S. Department of Health and Human Services. NCHS (National Center for Health Statistics). (2007). Health, United AHRQ, CAHPS (Agency for Healthcare Research and Quality, States, 2007 With Chartbook on Trends in the Health of Americans. Consumer Assessment of Healthcare Providers and Systems). (n.d.). Hyattsville, Md.: U.S. Department of Health and Human Services. Rockville, Md.: Center for Quality Improvement and Patient Safety, U.S. Department of Health and Human Services. NCHS (National Center for Health Statistics). (2005). Health, United States, 2005 With Chartbook on Trends in the Health of Americans. AHRQ, HCUP-SID (Agency for Healthcare Research and Quality, Hyattsville, Md.: U.S. Department of Health and Human Services. Healthcare Cost and Utilization Project-State Inpatient Databases). (2003, 2005). Rockville, Md.: Center for Delivery, Organization, NCHS, MCD (National Center for Health Statistics, and Markets, U.S. Department of Health and Human Services. Multiple Cause-of-Death Data Files). (n.d.). Hyattsville, Md.: Centers for Disease Control and Prevention. AHRQ, MEPS-IC (Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey-Insurance Component). NCHS, NIS (National Center for Health Statistics, National (2004, 2008). Washington, D.C.: U.S. Department of Health Immunization Survey). (2005, 2007). Hyattsville, Md.: and Human Services. http://www.meps.ahrq.gov. Centers for Disease Control and Prevention. CAHMI (Child and Adolescent Health Measurement Initiative). (2005, NCHS, NVSS (National Center for Health Statistics, 2009). National Survey of Children’s Health, 2003, 2007. Portland, National Vital Statistics System). (n.d.). Hyattsville, Md.: Ore.: Data Resource Center on Child and Adolescent Health, Centers for Disease Control and Prevention. Oregon Health and Science University. http://www.nschdata.org. Nolte and McKee. (2003). “Measuring the Health of Nations: CMS, MDS (Centers for Medicare and Medicaid Analysis of Mortality Amenable to Health Care.” London, U.K.: Services, Minimum Data Set). (n.d.). Baltimore, Md.: British Medical Journal Volume 327, November 15, 2003. U.S. Department of Health and Human Services. U.S. Census Bureau, Current Population Survey, Annual CMS, OASIS (Centers for Medicare and Medicaid Services, Social and Economic Supplement. (2005, 2006, 2007, 2008, Outcome and Assessment Information Set). (n.d.). Baltimore, 2009). Washington, D.C.: U.S. Department of Commerce. Md.: U.S. Department of Health and Human Services. CMS, SAF (Centers for Medicare and Medicaid Services, Standard Analytic File 5% Inpatient Data). (2003, 2006). Baltimore, Md.: U.S. Department of Health and Human Services. 103 About the Authors Douglas McCarthy, M.B.A., president of Issues Carter’s national health insurance task force. Prior Research, Inc., in Durango, Colo., is senior research to federal service, she was a research fellow at the advisor to The Commonwealth Fund. He supports Brookings Institution. She has authored numerous The Commonwealth Fund Commission on a High publications on health policy and insurance issues, Performance Health System’s Scorecard project, and national/international health system performance, conducts case studies of high-performing organiza- including the Fund’s 2006 and 2008 National Score- tions, and is a contributing editor to the bimonthly cards on U.S. Health System Performance and the 2007 newsletter Quality Matters. His 25-year career has edition of Aiming Higher, and coauthored the book spanned research, policy, operations, and consult- Health and the War on Poverty. She holds an under- ing roles for government, corporate, academic, and graduate degree in economics from Smith College and philanthropic organizations. He has authored and a graduate degree in economics from Boston College. coauthored reports and peer-reviewed articles on Joel C. Cantor, Sc.D., is the director of the Center a range of health care–related topics. A Chartbook for State Health Policy and professor of Public Policy on the Quality of Health Care in the United States, at Rutgers University. Dr. Cantor’s research focuses coauthored with Sheila Leatherman, was named by on issues of health care regulation, financing, and AcademyHealth as one of 20 core books in the field of delivery. His recent work includes studies of health health outcomes. Mr. McCarthy received his bachelor’s insurance market regulation, state health system per- degree with honors from Yale College and a master’s formance, and access to care for low-income and degree in health care management from the University minority populations. Dr. Cantor has published widely of Connecticut. During 1996–1997, he was a public on health policy topics, and serves on the editorial policy fellow at the Hubert H. Humphrey Institute of board of the policy journal Inquiry. He is a frequent Public Affairs at the University of Minnesota. advisor on health policy matters to New Jersey state Sabrina K. H. How, M.P.A., is senior research government and was the 2006 recipient of Rutgers associate for the Fund’s Commission on a High University President’s Award for Research in Service Performance Health System. She is coauthor of the to New Jersey. Dr. Cantor received his doctoral degree Commission’s 2006 and 2008 National Scorecards on in health policy and management from the Johns U.S. Health System Performance and the 2007 edition Hopkins Bloomberg School of Public Health. of Aiming Higher. Ms. How also served as program Dina Belloff, M.A., is a senior research analyst associate for two programs, Health Care in New York at the Rutgers Center for State Health Policy. Her City and Medicare’s Future. Prior to joining the Fund, research areas focus on health care access and af- she was a research associate for a management con- fordability, and health system performance. She has sulting firm focused on the health care industry. Ms. studied ways to optimize the performance of New How holds a B.S. in biology from Cornell University Jersey’s small group and nongroup health insurance and an M.P.A. in health policy and management from markets, and researched the sources of urban and New York University. nonurban disparities in health insurance coverage. In Cathy Schoen, M.S., is senior vice president at addition to her coauthorship on the 2007 and 2009 The Commonwealth Fund, a member of the Fund’s State Scorecards, Ms. Belloff is currently examining executive management team, and research director the impact of a policy in New Jersey that expands of the Fund’s Commission on a High Performance dependent coverage up to age 30. Prior to coming Health System. Her work includes strategic oversight to the Center, she was a research assistant at Math- of surveys, research, and policy initiatives to track ematica Policy Research. She received her bachelor’s health system performance. Previously Ms. Schoen degree with highest honors from Rutgers College and was on the research faculty of the University of Massa- a master’s degree in health policy studies from the chusetts’ School of Public Health and directed special Johns Hopkins University. projects at the UMass Labor Relations and Research Center. During the 1980s, she directed the Service Employees International Union’s research and policy department. Earlier, she served as staff to President 104 Further Reading Publications listed below can be found “In Chronic Condition: Experiences of Patients with on The Commonwealth Fund’s Web site Complex Health Care Needs, in Eight Countries, at www.commonwealthfund.org. 2008.” Cathy Schoen, Robin Osborn, Sabrina K. H. How, Michelle M. Doty, and Jordon Peugh. Health Out of Options: Why So Many Workers in Small Busi- Affairs Web Exclusive, Nov. 13, 2008, w1–w16. nesses Lack Affordable Health Insurance and How Health Care Reform Can Help (Sept. 2009) Michelle Losing Ground: How the Loss of Adequate Health M. Doty, Sara R. Collins, Sheila D. Rustgi, and Insurance Is Burdening Working Families—Findings Jennifer L. Nicholson. from the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2007 (Aug. 2008). Sara R. Paying the Price: How Health Insurance Premiums Collins, Jennifer L. Kriss, Michelle M. Doty, and Are Eating Up Middle-Class Incomes—State Health Sheila D. Rustgi. Insurance Premium Trends and the Potential of National Reform (Aug. 2009) Cathy Schoen, Jennifer Organizing the U.S. Health Care Delivery System for L. Nicholson, and Sheila D. Rustgi. High Performance (Aug. 2008). Anthony Shih, Karen Davis, Stephen Schoenbaum, Anne Gauthier, Rachel Rite of Passage: Why Young Adults Become Uninsured Nuzum, and Douglas McCarthy. and How New Policies Can Help, 2009 Update (Aug. 2009). Jennifer L. Nicholson, Sara R. Collins, Public Views on U.S. Health System Organization: A Bisundev Mahato, Elise Gould, Cathy Schoen, and Call for New Directions (Aug. 2008). Sabrina K. H. Sheila D. Rustgi. How, Anthony Shih, Jennifer Lau, and Cathy Schoen. Failure to Protect: Why the Individual Insurance Why Not the Best? Results from the National Scorecard Market Is Not a Viable Option for Most U.S. Families on U.S. Health System Performance, 2008 (July 2008). (July 2009). Michelle M. Doty, Sara R. Collins, The Commonwealth Fund Commission on a High Jennifer L. Nicholson, and Sheila D. Rustgi. Performance Health System. How Health Care Reform Can Lower the Costs of “How Many Are Underinsured? Trends Among U.S. Insurance Administration (July 2009). Sara R. Collins, Adults, 2003 and 2007.” Cathy Schoen, Sara R. Collins, Rachel Nuzum, Sheila Rustgi, Stephanie Mika, Cathy Jennifer L. Kriss, and Michelle M. Doty. Health Affairs Schoen, and Karen Davis. Web Exclusive, June 10, 2008, w298–w309. Fork in the Road: Alternative Paths to a High Perfor- The Building Blocks of Health Reform: Achieving mance U.S. Health System (June 2009). Cathy Schoen, Universal Coverage and Health System Savings (May Karen Davis, Stuart Guterman, and Kristof Stremikis. 2008). Karen Davis, Cathy Schoen, and Sara R. Collins. Front and Center: Insuring That Health Reform Puts People First (June 2009). Karen Davis, Kristof U.S. Variations in Child Health System Performance: Stremikis, Cathy Schoen, Sara R. Collins, Michelle A State Scorecard (May 2008). Katherine K. Shea, M. Doty, Sheila D. Rustgi, and Jennifer L. Nicholson. Karen Davis, and Edward L. Schor. The Path to a High Performance U.S. Health System: Bending the Curve: Options for Achieving Savings A 2020 Vision and the Policies to Pave the Way (Feb. and Improving Value in U.S. Health Spending (Dec. 2009). The Commonwealth Fund Commission on a 2007). Cathy Schoen, Stuart Guterman, Anthony High Performance Health System. Shih, Jennifer Lau, Sophie Kasimow, Anne Gauthier, and Karen Davis. 105 Aiming Higher: Results from a State Scorecard on Health System Performance (June 2007). Joel C. Cantor, Cathy Schoen, Dina Belloff, Sabrina K. H. How, and Douglas McCarthy. Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care (May 2007). Karen Davis, Cathy Schoen, Stephen C. Schoenbaum, Michelle M. Doty, Alyssa L. Holmgren, Jennifer L. Kriss, and Katherine K. Shea. Slowing the Growth of U.S. Health Care Expenditures: What Are the Options? (Jan. 2007). Karen Davis, Cathy Schoen, Stuart Guterman, Tony Shih, Stephen C. Schoenbaum, and Ilana Weinbaum. Why Not the Best? Results from the National Scorecard on U.S. Health System Performance (Sept. 2006). The Commonwealth Fund Commission on a High Per- formance Health System. 106 O N E E A ST 75TH STR E E T N E W YO R K , N Y 10 021-2692 T E L 2 12 . 6 0 6 . 3 8 0 0 FA X 212 . 6 0 6 . 35 0 0 w w w. co m m o nwe a l t hf u n d . o r g