Aiming Higher Results from a Scorecard on State Health System Performance 2015 Edition Douglas McCarthy, David C. Radley, and Susan L. Hayes December 2015 The COMMONWEALTH FUND overview Access and Affordability The fourth Commonwealth Fund Scorecard on State Health System Performance tells a story that is both familiar and new. Echoing the past three state scorecards, the 2015 edition finds extensive variation among states in people’s ability to access prevention and care when they need it, the quality of care treatment On most of the they receive, and their likelihood of living 42 indicators, a long and healthy life. However, this more states improved scorecard—the first to measure the effects than worsened. of the Affordable Care Act’s 2014 coverage expansions—also finds broad-based Avoidable Hospital Use improvements. On most of the 42 indicators, and Cost more states improved than worsened. By tracking performance avoidable hospital use measures across and cost, healthy lives, states, this scorecard and equity. Individual can help policymakers, indicators measure things health system leaders, like rates of children or healthy and the public identify adults who are uninsured, lives opportunities and set hospital patients who goals for improvement. get information about The 50 states and the how to handle their District of Columbia are recovery at home, hospital measured and ranked on admissions for children 42 indicators grouped with asthma, and into five dimensions: breast and colorectal access and affordability, cancer deaths, among equity prevention and treatment, many others. highlights from The top-ranked states are Minnesota, Vermont, Hawaii, Massachusetts, the scorecard Connecticut, New Hampshire, and Rhode Island. These states were also leaders in the 2014 scorecard. Washington moved up to the top quartile of state Improvements in Access performance for the first time in the scorecard series. from 2013 to 2014 The percentage of uninsured O verall, the highest-performing working-age adults declined states were clustered in the in nearly every state and Northeast and Upper Midwest. by 3 points or more in 39 states The percentage of uninsured children 18 years and younger declined by 2 points or more in 16 states The percentage of adults who Several of the states that went without care because of ranked in the bottom quartile of costs in the past year declined Overall performance, 2015 performance—Louisiana, Tennessee, by 2 points or more in Top quartile (12 states) Kentucky, and Oklahoma—were Second quartile (12 states + D.C.) Third quartile (13 states) Bottom quartile (13 states) among those that improved on the greatest number of indicators. Overall performance, 2015 21 states Top quartile (12 states) Second quartile (12 states + D.C.) Third quartile (13 states) Bottom quartile (13 states) There are wide variations in performance, with up to an R eductions in hospital readmissions accelerated in 2012, when eightfold difference between top- and bottom-ranked states. the federal government began financially penalizing hospitals with high rates of readmissions. Rates of potentially preventable National attention may be encouraging better quality of care in admissions to the hospital continued to fall in several states. hospitals and home health care settings and to more appropriate medication use in nursing homes and doctor’s offices. However, In recent years, health care spending growth moderated for declining rates of preventive care in several states signal the need Medicare beneficiaries across states, while premiums for for greater attention to prevention. employer-sponsored health plans continued to rise. 3 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org t overall Rankings os &($ost C/ se%(9$/ && C Hal.th ;- H-o/pi.t8$ ent Eq y L#e$s al#Ue%9 Across Dimensions H6e./: abl6eH-o/+. at#ent Ao-i*d.a%6 n &T4r)e/5# y 7s % m/ lth L-i $ pit8$U & t A!v + io & )# biliy % s 3 6# id#% $7 re/5 / !2 ve/t-i(o & rd.a/i0it ea/:0y%2# s %al#% vo+,.b ( T#at 3 +m -l Pr2e3 (3 ff*o+,a/0 -b d- % + r)e / A'() r -. of performance + P1#2#3 s &A!f')f*o+, s (-* nt3n %4 ive %& ($ 1) ces & !''( ; 2v ?@AG%C"()#"+)*% % e#n % ?@AG%C"()#"+)*% le A"c#e$s$ &% & s% ?@AB%C"()#"+)*%D+3E ty #+ 0% D+3E-3F #v - # "c % ?@AB%C"()#"+)*%D+3E-3F Eq ty D+3E-3F ui A!"c#$$ 2( , ui + !" 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New York 5$/6@&+? - - 3 3 3 3 - - ) ) 15 15 Delaware A$;(/(+$ Delaware A$;(/(+$ ) ) ) ) - - 3 3 - - 15 15 Oregon B+$=&# Oregon B+$=&# 3 3 3 3 ) ) - - ) ) 15 15 C&2'16A(?&'( Dakota South C&2'16A(?&'( South Dakota - - - - ) ) 3 3 - - 18 18 Maryland !(+D;(#9 Maryland !(+D;(#9 ) ) - - E E - - - - 18 18 F'(1Utah Utah F'(1 3 3 3 3 ) ) ) ) - - 20 20District of Columbia District of Columbia A"%'+"0'6&G64&;2,>"( A"%'+"0'6&G64&;2,>"( ) ) - - E E - - ) ) 20 20 New Jersey 5$/6H$+%$D New Jersey 5$/6H$+%$D - - - - 3 3 ) ) - - 20 20 I$##%D;J(#"( Pennsylvania I$##%D;J(#"( Pennsylvania ) ) ) ) 3 3 3 3 - - 23 23 California 4(;"G&+#"( California 4(;"G&+#"( 3 3 3 3 - - ) ) - - 23 23 Virginia *"+="#"( Virginia *"+="#"( - - - - 3 3 - - - - 25 25 Idaho :9(1& Idaho :9(1& E E 3 3 ) ) - - - - 26 26 Illinois :;;"#&"% Illinois :;;"#&"% - - - - E E - - - - 26 26 5&+'16A(?&'(Dakota North 5&+'16A(?&'( North Dakota - - - - - - 3 3 3 3 28 28 Kansas K(#%(% Kansas K(#%(% - - - - 3 3 3 3 3 3 28 28 Montana !&#'(#( Montana !&#'(#( E E 3 3 ) ) - - 3 3 28 28 Wyoming <D&,"#= Wyoming <D&,"#= 3 3 3 3 - - - - 3 3 31 31 Michigan !"01"=(# Michigan !"01"=(# - - - - 3 3 3 3 3 3 32 32 Alaska L;(%?( Alaska L;(%?( E E 3 3 ) ) 3 3 3 3 33 33 Arizona L+"M&#( Arizona L+"M&#( E E E E ) ) 3 3 - - 33 33 5$/6!$N"0&Mexico New 5$/6!$N"0& New Mexico E E E E ) ) 3 3 - - 33 33 Ohio B1"& Ohio B1"& - - - - 3 3 E E E E 36 36 Missouri !"%%&2+" Missouri !"%%&2+" 3 3 - - 3 3 E E 3 3 37 37 Florida O;&+"9( Florida O;&+"9( E E 3 3 3 3 - - 3 3 37 37 5&+'164(+&;"#( North Carolina 5&+'164(+&;"#( North Carolina 3 3 3 3 3 3 3 3 E E 39 39 <$%'6*"+="#"(West Virginia <$%'6*"+="#"( West Virginia 3 3 - - E E E E 3 3 40 40 Kentucky K$#'20?D Kentucky K$#'20?D 3 3 - - E E E E E E 40 40 C&2'164(+&;"#( South Carolina C&2'164(+&;"#( South Carolina E E 3 3 - - E E E E 40 40 Texas P$N(% Texas P$N(% E E E E 3 3 - - 3 3 43 43 Indiana :#9"(#( Indiana :#9"(#( 3 3 3 3 3 3 E E E E 43 43 Nevada 5$J(9( Nevada 5$J(9( E E E E - - 3 3 E E 43 43 Tennessee P$##$%%$$ Tennessee P$##$%%$$ 3 3 3 3 E E E E E E 46 46 Georgia Q$&+="( Georgia Q$&+="( E E E E 3 3 E E E E 47 47 Alabama L;(>(,( Alabama L;(>(,( 3 3 3 3 E E E E E E 48 48 Louisiana R&2"%"(#( Louisiana R&2"%"(#( 3 3 E E E E E E E E 49 49 Arkansas L+?(#%(% Arkansas L+?(#%(% E E E E 3 3 E E E E 50 50 Oklahoma B?;(1&,( Oklahoma B?;(1&,( E E E E E E E E E E 51 51 Mississippi !"%%"%%"77" Mississippi !"%%"%%"77" E E E E E E E E E E 4 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org about the scorecard series Number of Indicators Improved or Worsened This 2015 edition of the Scorecard by State on State Health System Performance is the fourth in an ongoing series. No. of Indicators No. of Indicators WORSENED IMPROVED Previous state scorecards were 5 Alabama 7 published in 2007, 2009, and 2014. 5 Alaska 11 The 2014 scorecard assessed changes 3 Arizona 12 from 2007 to 2012, which included 2 Arkansas 11 the 2007–2009 recession but stopped 2 California 11 1 Colorado 9 short of major coverage expansions 4 Connecticut 8 under the Affordable Care Act (ACA). 3 Delaware 8 2 District of Columbia 12 The 2015 edition measures changes in 1 Florida 10 2 Georgia 11 performance during 2013 and 2014 to 4 Hawaii 6 assess the effects of the ACA’s 2014 4 Idaho 8 health insurance expansions, 2 Illinois 8 3 Indiana 6 as well as early effects of health care 2 Iowa 9 delivery and payment reforms like 1 Kansas 10 accountable care organizations and 3 Kentucky 13 3 Louisiana 16 financial incentives to reduce hospital 3 Maine 6 readmissions. The effects of the ACA 2 Maryland 11 are not yet fully reflected in the 2015 4 Massachusetts 11 scorecard results. It may take many 2 Michigan 8 4 Minnesota 8 years to see the resulting changes. 4 Mississippi 11 1 Missouri 9 Annual updates in this series will 3 Montana 10 2 Nebraska 5 document the trajectory of states’ 3 Nevada 12 performance as changes shaped by 4 New Hampshire 8 public policy and the private market 2 New Jersey 9 continue to unfold. 3 New Mexico 9 1 New York 8 1 North Carolina 10 See Methods, page 19, for a complete 5 North Dakota 11 description of scorecard methods and 2 Ohio 7 2 Oklahoma 14 indicators. See appendices for state- 3 Oregon 11 Notes: Based on trends for specific rates for each indicator. Also 3 Pennsylvania 5 36 of 42 total indicators; see a companion brief, The Changing 3 Rhode Island 14 trend data are not available for all indicators. Landscape of Health Care Coverage and 1 South Carolina 6 Ambulatory care–sensitive Access: Comparing States’ Progress in 2 South Dakota 9 conditions among Medicare 0 Tennessee 13 beneficiaries from two age the ACA’s First Year. 4 Texas 6 groups are considered a 2 Utah 5 single indicator in tallies of improvement. Improvement 4 Vermont 8 or worsening refers to 2 Virginia 6 a change between the 3 Washington 11 baseline and current time 5 West Virginia 11 periods of at least 0.5 3 Wisconsin 5 standard deviations larger than the difference in rates 7 Wyoming 10 across all states over the two years being compared. 5 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org 2015 RANKING 2015 Scorecard on State Health System Performance key findings 1 Massachusetts access and T he number of 2 Vermont Children ages 0–18 uninsured children who were uninsured 3 Minnesota across all states fell by 2 percentage 4 Rhode Island points or more in 2013 2014 Connecticut 5 affordability 16 states. T 8% 6% he number of adults who said they went without care because of costs fell by 5 7 7 9 Maryland District of Columbia Iowa Delaware Being able to get—and afford—health care when you 2 percentage points or more in 21 states. 9 New Hampshire need it are fundamental elements of a well-functioning In Oregon, the rate fell the most—from 18 percent to 14 percent of adults. 11 Hawaii health care system. One key measure of access to care 12 Pennsylvania is rates of insurance: do people have health insurance Adults who went without care Wisconsin 13 coverage that makes it possible for them to seek because of cost in the past year 14 New York 2013 2014 medical care when they are sick and get the preventive 15 Michigan services they need to stay healthy? Health insurance also 18% 16 Maine protects individuals and their families from burdensome 16% 16 Ohio costs in the case of an accident or illness. In 2014, the 14% 14% 16 Washington Affordable Care Act expanded access for many millions 19 Illinois of Americans by creating health insurance marketplaces 19 Virginia that offer coverage—with subsidies for those eligible— 21 New Jersey and providing federal funding to states to expand U.S. average Oregon 22 South Dakota Medicaid eligibility for low-income residents. 23 Kansas T he percentage of adults under age 65 23 Nebraska who had high out-of-pocket spending The greatest improvement: relative to their income ranged from 25 26 North Dakota Colorado Between 2013 and 2014, the uninsured rates for adults 10 percent in Maryland to 22 percent in 26 West Virginia ages 19–64 fell by 3 percentage points or more in Idaho and Tennessee. 28 Kentucky 39 states Individuals with high out-of-pocket 28 Oregon Across the medical spending,a 2013–2014 30 California country, the 30 North Carolina uninsured 22% 22% rates among 32 Alabama working-age U.S. AVERAGE 15% 33 Missouri adults ranged 34 Indiana from 5% in Massachusetts 34 Tennessee to 26% in Texas. 10% 36 Utah 5% 36 Wyoming massachusetts 38 Louisiana Maryland Idaho Tennessee 39 Montana a Defined as out-of-pocket medical expenses equaling 10 percent 40 Florida 26% or more of annual household income, or 5 percent or more of income if low income (below 200% of the federal poverty level). 41 Georgia texas To ensure adequate sample size, state-level estimates are an average of rates found in 2013 and 2014. 41 South Carolina 43 Arizona Ten states—Alaska, Florida, Georgia, 44 Alaska Louisiana, Mississippi, Nevada, New California, Florida, Montana, Mexico, Oklahoma, South Carolina, and 44 Arkansas Oklahoma, Oregon, and Texas—had rates of uninsured adults in 46 Idaho Rhode Island 2014 that were 20 percent or higher. 46 New Mexico Of these, only Nevada and New Mexico Mississippi Improved on the greatest 4 OF 6 expanded their Medicaid programs as of 48 48 Oklahoma number of indicators January 2014 (Alaska did in 2015). 50 Nevada 51 Texas 6 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Change in state health system performance by indicator Number of states that: Improved Little or no change Worsened Adults ages 19–64 uninsured 39 12 Adults who went without care 21 30 because of cost in the past year Children ages 0–18 uninsured 16 35 At-risk adults without a doctor visit 11 38 2 Adults without a dental visit in past year 42 9 Notes: This exhibit measures indicator change over the two most recent years of data available. See Appendix A1 for baseline and current data years for each indicator. Trend data are not available for all indicators. Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. The "little or no change" category includes the number of states with changes of less than 0.5 standard deviations, as well as states with no change or without sufficient data to assess change over time. Adult uninsured rates declined in all states and D.C. from 2013 to 2014 except for Massachusetts where the rate did not change; in the remaining 11 states, the decline was less than 0.5 standard deviations. High out-of-pocket spending indicator is not included because data are not comparable to prior years. Ten states had declines of 6 to 9 percentage points in uninsured rates for working-age adults 30% 2013 2014 25% 20% 15% 10% 5% 0% Hawaii* Vermont* Iowa* Minnesota* Connecticut* Wisconsin* New York* Ohio* New Hampshire* South Dakota* Washington* West Virginia* New Jersey* California* Arizona* Arkansas* Colorado* Illinois* Delaware* North Dakota* Rhode Island* Maryland* Michigan* Kentucky* Oregon* Kansas* Tennessee* Idaho* Montana* North Carolina* South Carolina* Nevada* Mississippi* New Mexico* Oklahoma* Georgia* Louisiana* Florida* Texas* District of Columbia Massachusetts Pennsylvania Maine Virginia Missouri Utah Indiana Wyoming Alabama Nebraska Alaska These states all expanded their Medicaid programs by January 1, 2014. Note: States are arranged in rank order based on their current data year (2014) value. * Denotes states with at least -.5 standard deviation change (3 percentage points) between 2013 and 2014. Data: 2013 and 2014 American Community Survey (ACS), Public Use Microdata Sample (PUMS). future implications If all states performed as well as the top-performing state: More than Nearly Nearly 24 million 12 million 17 million additional adults fewer people would fewer adults and children be burdened by high would forgo would gain health medical spending needed care insurance. relative to income. because of cost. 7 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org 2015 RANKING 2015 Scorecard on State Health System Performance key findings 1 Maine PREvention 2 Massachusetts Patients’ hospital experiences have 3 Rhode Island improved steadily in recent years 4 New Hampshire and treatment 4 Vermont Although changes in hospital quality 4 Wisconsin may be modest from year to year, all 7 Pennsylvania states improved between 2007 and 2013 8 Minnesota on two indicators of patient-reported Patients and their families have the right to care experiences in the hospital. These 9 Colorado 9 Connecticut expect care that is effective, coordinated among measures have received heightened 9 Delaware their different physicians and other providers, attention through public reporting of 9 Iowa hospital performance and, for measures and respectful of their values and preferences. of patient education, as part of national 13 Nebraska The Prevention and Treatment dimension efforts to reduce hospital readmissions. 14 Maryland South Dakota assesses these factors by measuring the quality 14 Percent of hospitalized patients who reported 16 Kansas of care provided in hospitals, nursing homes, hospital staff always managed pain well, 16 Michigan doctors’ offices, and patients’ homes. responded when needed help to get to 18 Hawaii bathroom or pressed call button, and explained 19 North Dakota medicines and side effects 20 Kentucky Best-performing state (highest rate) The greatest improvement: U.S. average 21 District of Columbia in 45 states Worst-performing state (lowest rate) 21 Illinois U.S. U.S. 21 Missouri average average 21 New Jersey patients who were hospitalized for heart attack, 62 68 21 Ohio heart failure, or pneumonia were substantially 80% 70% 21 Virginia less likely to die within 30 days of their 60% 21 West Virginia hospital stay, compared with the previous 50% 28 New York three-year measurement period. 40% 30% 28 South Carolina 20% 28 Utah 10% Idaho 31 0% 31 Montana 07 08 09 10 11 12 13 North Carolina 20 20 20 20 20 20 20 31 Nationally, the rate (known Percent of hospitalized patients given 34 Indiana as hospital information about what to do during their 34 Wyoming 30-day mortality) recovery at home 36 Oregon dropped by U.S. U.S. average 37 Alabama average 79 86 37 Alaska 100% 37 California 90% 37 Florida 80% 70% 37 Tennessee 3.8% 60% 50% 37 Washington Louisiana —an improvement that 43 40% has saved many lives. 44 Oklahoma 30% 45 Georgia 20% Louisiana 10% 45 New Mexico 0% 47 Arizona Improved on the greatest 8 16 47 Arkansas 07 08 09 10 11 12 13 OF 20 20 20 20 20 20 20 number of indicators Data: CMS Hospital Compare. 47 Mississippi 50 Texas 51 Nevada 8 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Change in state health system performance by indicator Number of states that: Improved Little or no change Worsened Hospital 30-day mortality 45 6 Home health patients who get better at walking or moving around 41 10 Elderly patients who received a high-risk prescription drug 35 16 Nursing home residents with an antipsychotic medication 27 24 Elderly patients who received a contraindicated prescription drug 27 23 1 Children ages 19–35 months with all recommended vaccines 22 13 16 High-risk nursing home residents with pressure sores 14 36 1 Hospital discharge instructions for home recovery 13 37 1 Adults with a usual source of care 8 41 2 Older adults with recommended preventive care 6 30 15 Patient-centered hospital care 3 48 Home health patients whose wounds 3 43 5 healed after an operation Notes: This exhibit measures indicator change over the two most recent years of data available. See Appendix A1 for baseline and current data years for each indicator. Trend data are not available for all indicators. Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. The "little or no change" category includes the number of states with changes of less than 0.5 standard deviations, as well as states with no change or without sufficient data to assess change over time. vaccinations in children High rates of Children ages 19–35 months who received all recommended doses of seven vaccines 2013 vaccinations protect 2014 90% the population from communicable diseases. 80% Among children ages 70% 19 to 35 months, the 60% percentage receiving all seven recommended 50% vaccines on time 40% increased by 3 points or more in 22 states 30% from 2013 to 2014 while 20% decreasing by a similar 10% magnitude in 15 states and D.C. Nationally, 0% more than 1 of 4 Wyoming* Connecticut* South Carolina* District of Columbia* Nevada* Ohio* New Jersey* Washington* Indiana* Michigan* Texas* West Virginia* Maine* North Carolina* New Hampshire* Pennsylvania* California* New Mexico* Iowa* Minnesota* Mississippi* Utah* Alaska* Arkansas* Idaho* Kansas* Rhode Island* Delaware* Massachuseatts* Georgia* Hawaii* Virginia* Colorado* Florida* Louisiana* Oklahoma* Tennessee* Vermont* Illinois Kentucky New York North Dakota Wisconsin Missouri Montana Arizona Oregon Nebraska Alabama South Dakota Maryland young children were not up-to-date on all recommended vaccines in 2014, a rate little- changed from 2013. +17 percentage points -8% percentage points greatest increase greatest decrease Notes: States are arranged in rank order based on their current data year (2014) value. *Denotes states with at least -.5 standard deviation change (3 percentage points) between 2013 and 2014. Recommended vaccines are the 4:3:1:3:3:1:4 series, which includes ≥4 doses of DTaP/DT/DTP, ≥3 doses of poliovirus vaccine, ≥1 doses of measles-containing vaccine, full series of Hib (3 or 4 doses, depending on product type), ≥3 doses of HepB, ≥1 dose of varicella vaccine, and ≥4 doses of PCV. Data: 2013 and 2014 National Immunization Surveys. 9 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org older adults Among adults 50 and older, the share who reported receiving When adults receive home health care, it is critical that they all appropriate preventive care services—like cancer receive help in regaining functional abilities, like walking.3 In 41 screenings and flu shots—declined by 2 percentage points or states, there were gains of at least 2 percentage points between more in 15 states between 2012 and 2014. 2013 and 2014 in the share of home health patients who got better at walking or moving around. Even in Connecticut, the best- Older adults who received recommended performing state, less than half preventive care in of older adults received all Home health patients who got better at walking or moving around Connecticut, 2014 the recommended services in the appropriate time frame.1 69% Although the ACA requires most 61% 63% insurance plans to cover certain preventive services with no 48% cost-wsharing, other factors— like patient awareness and physicians’ recommendations— 2013 2014 2014 can be factors in whether adults U.S. average Utah receive services.2 Best-performing state Elderly patients who received a In 35 states, there was a reduction of at In 27 states, there was a promising high-risk prescription drug least 3 percentage points between 2011 reduction of at least 2 percentage and 2012 in the share of elderly Medicare points in the use of antipsychotic beneficiaries who received a high-risk drugs in nursing homes, where prescription medication that should be they are sometimes inappropriately avoided for elderly people. This improvement prescribed to chemically restrain 20% 17% may reflect actions taken by the Food and Drug Administration that led to a high-risk residents with cognitive impairments or difficult behaviors.5 9% drug being removed from the market, as well as providers’ increased awareness of 2011 2012 U.S. average 2012 Massachusetts drug safety concerns and the increased use of electronic prescribing tools that alert future providers when unsafe drugs are ordered.4 implications Best-performing state What Is an Unsafe Drug? If all states performed as well as the top-performing state: Certain medications that are commonly taken by younger patients without incident can put those age 65 and older at increased risk for experiencing severe side effects and complications such as confusion, sedation, immobility, falls, and More than 8 million fractures. The National Committee for Quality Assurance has identified more than 100 high-risk medications that should be avoided in the elderly, ranging from antianxiety drugs and antihistamines to narcotics and muscle relaxants. Safer additional older adults would alternatives may be available, but these potentially harmful medications are still receive key recommended frequently prescribed to the elderly. preventive care services such as cancer screenings and flu shots. 10 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org 2015 RANKING 2015 Scorecard on State Health System Performance key findings 1 Hawaii Hospitalizations for ambulatory avoidable hospital use 2 Oregon –care sensitive conditions 3 Idaho and costs of care Among Medicare beneficiaries ages 65 to 74, hospital admissions for ambulatory care– sensitive conditions—that is, conditions that 4 5 Washington Colorado 5 Montana can be managed outside the hospital, like Utah 5 Inefficient or wasteful health care, along with high hypertension—fell 2 percent from 2007 to 2008 8 Minnesota costs, are among the chief problems burdening and then an average 6 percent annually between 2008 and 2013. 8 South Dakota our health care system. To measure inefficiency, Alaska Worst-performing state (highest rate) 10 this scorecard dimension focuses on rates of U.S. average 10 Arizona potentially avoidable and expensive hospital care. It Best-performing state (lowest rate) 10 New Mexico also looks at two cost measures: the average cost 60 13 Vermont of an individual employer-based health insurance Rate per 1,000 Medicare beneficiaries 50 14 California premium and average annual spending per Medicare 14 Nebraska 40 beneficiary. Many studies have found that higher 14 Wisconsin spending is not systemically associated with better 30 14 Wyoming outcomes. The Affordable Care Act encourages 20 18 Iowa changes to the way we deliver and pay for care Worst-performing state (highest rate) 18 Nevada 10 and encourages new models, like accountable care U.S. average Best-performing state (lowest rate) 18 New Hampshire organizations and bundled payment arrangements. 0 21 Maine 60 07 22 North Dakota 08 09 10 11 12 13 20 20 20 20 20 20 20 Rhode Island Rate per 1,000 Medicare beneficiaries 1,000 Medicare beneficiaries 50 22 The greatest improvement: The worst-performing states improved the most for40 indicator in 2013. The rate fell 16 percent this 24 Delaware in 23 states there were reductions of 2 percentage points or in Oklahoma and 14 percent in West Virginia; rates varied about threefold across states. 30 70 24 26 26 South Carolina New York North Carolina more between 2010 and 2012 in rates of hospital 30-day hospital readmissions 20 60 28 Connecticut Rate per readmissions among Medicare beneficiaries The hospital readmission rate for Medicare 10 28 Georgia beneficiaries fell by 10.5 percent in 2012 and 50 receiving postacute care in nursing homes. 28 Virginia 10.8 0percent in 2013, after declining an average 40 31 Kansas 3.8 percent annually between 2007 and 2011. 07 08 09 10 11 12 13 20 20 20 20 20 20 20 In October 2012, the Medicare program began 30 31 Massachusetts financially penalizing hospitals with high rates 33 Florida of readmissions, motivating hospitals to reduce 20 33 Pennsylvania readmissions to avoid these penalties.6 10 33 Texas 70 36 Indiana The biggest 0 reduction—of 60 36 New Jersey Rate per 1,000 Medicare beneficiaries 4 percentage 07 08 09 10 11 12 13 38 Arkansas 20 20 20 20 20 20 20 points—was 50 38 Michigan in Maryland. Data: Ambulatory-care sensitive hospitalizations & 40 30-day readmissions: Medicare claims via Feb. 2015 38 Missouri CMS Geographic Variation Public Use File. 38 Ohio 30 42 Maryland 20 42 Tennessee 44 Illinois 10 45 District of Columbia Louisiana, Massachusetts, 0 46 Alabama and Tennesee Oklahoma 07 08 09 10 11 12 13 46 20 20 20 20 20 20 20 Improved on the greatest 5 OF 9 Data: Ambulatory-care sensitive hospitalizations & 48 West Virginia number of indicators 30-day readmissions: Medicare claims via Feb. 2015 CMS Geographic Variation Public Use File. 49 50 Kentucky Louisiana 51 Mississippi 11 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org avoidable hospital use Long-term care for elderly Americans Wide state variation on indicators of potentially avoidable is often funded by state Medicaid hospital use suggests opportunities for improvement Top state programs, while their hospital stays Bottom state 31% 30% and postacute care are paid for by Medicare. Postacute care in either 25% patients’ homes or institutions, 20% 26% U.S. AVERAGE 20% 17% like skilled nursing facilities, is the U.S. AVERAGE 16% U.S. AVERAGE greatest source of Medicare spending 15% 17% variation.7 Hospital admissions or 10% 13% 13% readmissions from these settings can often be avoided with good 5% 7% transitional care and proactive 0% patient monitoring and intervention.8 Long-stay nursing home Short-stay nursing home Home health patients with residents with a hospital residents with a 30-day a hospital admission admission (2012) readmission to the hospital (2012) (10/2013–9/2014) There was considerable variation among states in hospital admission and Data: Nursing home admissions/readmissions: V. Mor, Brown University, analysis of 2012 Medicare enrollment data, readmission rates among nursing home Medicare Provider and Analysis Review (MedPAR), and Minimum Data Set (MDS) data; Home health admissions: authors’ residents and home health patients. analysis of CMS Medicare claims data from CMS Home Health Compare. States with the highest hospital readmission rates�in 2012 tended to have the largest reductions in 2013 2012 2013 60 Rate of 30-day hospital readmissions per 1,000 Medicare beneficiaries 50 U.S. average, 2012 40 34 30 30 20 U.S. average, 2013 10 0 Illinois* District of Columbia* Texas* New York* Connecticut* Tennessee* Alabama* Indiana* Louisiana* Oklahoma* Massachusetts* West Virginia* New Jersey* Mississippi* Maryland* Kentucky* Arkansas* South Carolina Hawaii Florida Ohio New Hampshire North Carolina Oregon Idaho Utah Minnesota Colorado New Mexico Arizona Washington California Montana Nevada Wisconsin Rhode Island Pennsylvania Alaska South Dakota Vermont Maine Wyoming Georgia Iowa Nebraska North Dakota Missouri Michigan Kansas Virginia Delaware Notes: States are arranged in order (lowest to highest) of their readmission rate in 2012. *Denotes states with at least -.5 standard deviation change (5 readmissions per 1,000) between 2012 and 2013. Data: Medicare claims via Feb. 2015 CMS Geographic Variation Public Use File. 12 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Change in state health system performance by indicator Number of states that: Improved Little or no change Worsened Short-stay nursing home residents with 23 28 a 30-day readmission to the hospital Medicare 30-day hospital readmissions, per 1,000 beneficiaries 17 34 Home health patients with a hospital admission 10 35 6 Medicare admissions for ACS conditions, age 75 and older 8 43 Potentially avoidable emergency department visits among Medicare beneficiaries 7 44 Medicare admissions for ACS conditions, ages 65–74 6 45 Long-stay nursing home residents with a hospital admission 6 45 Hospital admissions for pediatric asthma, per 100,000 children 3 45 3 Health insurance premium for employer-sponsored 2 18 31 single-person plans Total Medicare (Parts A & B) reimbursements per enrollee 51 Notes: This exhibit measures indicator change over the two most recent years of data available. See Appendix A1 for baseline and current data years for each indicator. Trend data are not available for all indicators. Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. The "little or no change" category includes the number of states with changes of less than 0.5 standard deviations, as well as states with no change or without sufficient data to assess change over time. ACS=ambulatory care–sensitive. cost of care National per-beneficiary Trend in national health expenditures future Medicare spending grew by 7.8 percent between 2008 and Cumulative percent change from baseline year 25% 21% Privately insured per- implications 2013, representing average 17% enrollee annual growth of 1.9 percent. 13% spending If all states performed as well In contrast, among people 9% Medicare per- as the top-performing state: 5% beneficiary with private health insurance, spending 1% spending grew more rapidly 08 09 10 11 12 12 13 during the same period: by Medicare beneficiaries 20 20 20 20 20 20 20 23.9 percent, or average annual Data: CMS Office of the Actuary, National Health Expenditure Historical Tables, 2013; would have over 1.4 million Table 21. growth of 5.5 percent.9 Per-person Medicare spending State change: Medicare spending and employer- growth between 2008 and sponsored health insurance premiums 2013 was 8 percent or less in Number of states and D.C. with fewer emergency room visits for care 31 states and higher than 15 Less than or equal to 8% growth, 2008–2013 15% to 29% growth, 2008–2013 that could be provided outside the 30% or higher growth, 2008–2013 percent in only North Dakota 9% to 14% growth, 2008–2013 emergency room. Medicare spending per beneficiary and South Dakota. 31 18 2 Average health insurance premiums for employer- Single-person employer-sponsored insurance premium Children between 2 and 17 sponsored individual plans would endure about 34 17 85,000 increased in every state between 2008 and 2013, with Notes: State change reflects 2008 to 2013; 2014 data on ESI premiums used in Scorecard rankings are excluded for comparability to Medicare data. Medicare growth ranging from 16 percent spending estimates exclude prescription drug costs and reflect only the age 65+ in Arkansas to 39 percent in Medicare fee-for-service population. For measuring trend, Medicare spending and fewer asthma-related insurance premiums are unadjusted. South Dakota, North Dakota, Data: Medicare spending: Medicare claims via Feb. 2015 CMS Geographic Variation hospital admissions. Public Use File; Insurance premiums: 2008–2013 Medical Expenditure Panel Survey. Ohio, and Alaska. 13 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org 2015 RANKING 2015 Scorecard on State Health System Performance key findings 1 Minnesota HEALTHY LIVES D eaths from Breast cancer deaths per 2 Colorado 100,000 female population Connecticut breast cancer 2 fell in 13 states, 2012 2013 4 Massachusetts while deaths from colorectal cancer 21.4 20.8 4 6 Utah Hawaii Having insurance and getting care are dropped in Colorectal cancer deaths per 100,000 population 7 California not the only factors that contribute to a 10 states, 7 New Hampshire between 2012 2012 2013 9 Vermont healthy population. This dimension includes and 2013. 14.9 14.6 10 Rhode Island measures that affect people’s ability to 10 Washington Mortality Amenable to Health Care 12 New Jersey lead long and healthy lives—like rates of T his measure refers to premature deaths 13 New York smoking, premature death, and obesity. (from certain diseases like diabetes 14 Nebraska or hypertension) that could have been 14 Oregon prevented with effective and timely health 16 Iowa care. Although there was little change 17 Idaho The greatest improvement: in this measure during the time period 18 Wisconsin Reducing the number measured by the 2015 scorecard, looking at a longer trend shows that the rate of 18 Wyoming of adults who smoke. these premature deaths fell 14 percent 20 20 Maryland Virginia during the past decade—from 98 deaths 22 District of Columbia per 100,000 people in 2004–05 to 84 in 22 Florida 2012–13. 22 Illinois Worst-performing state (highest rate) Montana 22 U.S. average 26% Best-performing state (lowest rate) 22 Texas west virginia 180 27 Kansas 160 27 North Dakota 29 Arizona 140 29 Maine Deaths per 100,000 population 120 98 29 South Dakota 9% 100 84 32 Alaska Utah 33 Delaware 80 34 New Mexico 60 34 Pennsylvania 15 states + D.C. 40 20 36 36 Nevada North Carolina saw their smoking Across the country, 0 38 Michigan 39 Georgia rates drop by 2 to 3 the smoking rate 5 7 9 1 3 Missouri –0 –0 –0 –1 –1 among adults 40 percentage points 04 06 08 10 12 20 20 20 20 20 ranged from 9% in 41 Ohio between 2013 and 2014. Utah to 26% in Note: Age-standardized deaths before age 75 from select causes. 42 Indiana West Virginia. Data: 2004–2013 National Vital Statistics System (NVSS) 43 South Carolina Mortality All-County Micro Data Files. 44 Kentucky 44 Tennessee – The largest reductions occurred in states D.C. 46 Alabama that had the highest rates to start with— 46 Oklahoma for example, since 2004–05, premature Improved on the greatest 5 11 48 Louisiana OF deaths dropped 19 percent in Nevada, number of indicators from 114 to 92 per 100,000 people. 49 Arkansas 50 West Virginia 51 Mississippi 14 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Change in state health system performance by indicator Number of states that: Improved Little or no change Worsened Adults who smoke 16 35 Breast cancer deaths per 100,000 female population 13 30 8 Colorectal cancer deaths per 100,000 population 10 37 4 Infant mortality, deaths per 1,000 live births 10 33 8 Adults who have lost six or more teeth 6 44 1 Adults who are obese 3 37 11 Adults with poor health‐related quality of life 3 35 13 Suicide deaths per 100,000 population 2 44 5 Mortality amenable to health care 51 Years of potential life lost before age 75 51 Notes: This exhibit measures indicator change over the two most recent years of data available. See Appendix A1 for baseline and current data years for each indicator. Trend data are not available for all indicators. Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. The "little or no change" category includes the number of states with changes of less than 0.5 standard deviations, as well as states with no change or without sufficient data to assess change over time. disparity finding A frican Americans are more likely than whites to die early from a treatable future 200 condition in every state (where data are available). implications Black If all states performed as well White as the top-performing state: 150 Deaths per 100,000 population There would be approximately 100 84 U.S. 84,000 fewer premature deaths average 50 for all races before age 75 for conditions that can be detected early and 0 effectively treated with Mississippi Massachusetts Connecticut New Jersey Oklahoma Michigan Alaska Maine Washington Minnesota Rhode Island New Mexico Colorado Hawaii Oregon Arizona North Carolina Ohio Texas Alabama Missouri Illinois Tennessee District of Columbia Louisiana Arkansas Delaware Maryland Florida New York Virginia Nebraska Nevada Kansas California Iowa Georgia West Virginia United States Kentucky South Carolina Indiana Wisconsin Utah Pennsylvania good follow-up care. There would be nearly The greatest disparities in rates between white and black deaths were in D.C. 8 million fewer adults (ages 18 to 64) (186 vs. 41 per 100,000), Illinois (178 vs. 76), and Michigan (190 vs. 77). who would lose six or more teeth to decay, infection, Notes: Data for black race are not available for Idaho, Montana, New Hampshire, North Dakota, South Dakota, Vermont, or Wyoming. States are arranged in rank order based on black mortality. or gum disease. Data: 2012 and 2013 National Vital Statistics System (NVSS) Mortality All-County Micro Data Files. 15 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org 2015 RANKING 2015 Scorecard on State Health System Performance key findings 1 Hawaii equity 2 Massachusetts E very state improved on 3 Connecticut at least five equity indicators. 3 Vermont rhode island 5 New Hampshire had the most improved 5 New York When health care is inequitable, there are disparities in access equity indicators with 19 7 Rhode Island and availability of care (e.g., the number of people who have insurance or who visit a dentist regularly) and health status 8 Washington (e.g., the number of people who are obese or smokers) 9 District of Columbia between various groups based on different factors, like their 9 Minnesota income level. Across the nation, health care equity remains 11 Colorado an unfulfilled goal. However, the health insurance expansions 11 Oregon of the Affordable Care Act offer the opportunity to close 13 Maryland these gaps. The Equity dimension looks at two vulnerable Delaware 14 populations—low-income people and those who belong to racial 15 Iowa and ethnic minorities. States’ performance is based on gaps in F or most equity indicators, however, 15 Maine equity—that is, the difference between the state’s vulnerable population and the U.S. average for any given indicator. there were states for which the gap 17 New Jersey Improvement is defined as a decline in the states’ vulnerable widened, meaning performance 17 South Dakota group rate and a narrowing in the performance gap between worsened for the most vulnerable 19 Pennsylvania the vulnerable group and the U.S. average. group and the gap grew between that 20 Nebraska group and the U.S. average. 20 New Mexico 22 California income disparities 22 Idaho 24 Arizona The greatest improvement: F or the equity gaps based on income, more states improved than worsened. 24 Illinois Widespread reductions in the percentage of low-income elderly 24 Utah adults who received a high-risk prescription medication At least half the states improved on six 24 Virginia in 37 states, indicators: rates of nonelderly uninsured, elderly patients who received a high-risk 28 Missouri prescription medication, three measures 29 Alaska the percentage of low-income elderly adults Wisconsin of avoidable hospital use among Medicare 29 receiving a high-risk prescription medication beneficiaries who also receive Medicaid, 31 Florida declined and the equity gap narrowed. and nonelderly adults who have lost six 31 Michigan or more teeth due to gum disease. The 31 Texas Rhode Island majority of states worsened on only one West Virginia Improved on the greatest number of indicators 12 15 OF 31 indicator: rates of obesity among adults. 35 Wyoming 36 Kansas 36 Montana racial/ethnic disparities 36 North Dakota The greatest improvement: F or the equity gaps based on race or ethnicity, more states worsened 39 39 Nevada Tennessee Premature death rates among states’ racial and ethnic minority populations declined in most states than improved. At least half the states 41 Ohio improved on three indicators: rates in 34 states, 42 Alabama of nonelderly uninsured, mortality 43 North Carolina amenable to health care, and infant 44 Louisiana death rates from conditions amenable to mortality, but at least half worsened 45 Georgia health care interventions declined and on six others. 45 Kentucky the equity gap narrowed. 47 Indiana 48 South Carolina Arizona, Illinois, North Carolina, New York, Oklahoma, California, and Florida Improved on the greatest number of indicators 8 OF 13 49 Mississippi 49 Oklahoma 51 Arkansas 16 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Change in state health system performance by indicator Income Number of states where equity: Improved No change Worsened Uninsured ages 0–64 28 23 Adults who went without care because of cost in past year 19 25 7 At-risk adults without a doctor visit 11 21 19 Adults without a dental visit in past year 16 12 23 Adults without a usual source of care 16 12 23 Older adults without recommended preventive care 18 19 14 Children ages 19–35 months without all recommended vaccines 21 13 17 Elderly patients who received a high-risk prescription drug 37 14 Medicare admissions for ambulatory care–sensitive conditions 34 15 2 Medicare 30-day hospital readmissions, per 1,000 beneficiaries 35 12 4 Potentially avoidable emergency department visits among Medicare beneficiaries, per 1,000 beneficiaries 27 14 10 Adults with poor health-related quality of life 17 15 19 Adults who smoke 12 17 22 Adults who are obese 14 7 30 Adults who have lost six or more teeth 25 8 18 Race/Ethnicity Uninsured ages 0–64 26 23 2 Adults who went without care because of cost in past year 22 12 17 At risk adults without a doctor visit 13 6 32 Adults without a dental visit in past year 11 11 29 Adults without a usual source of care 14 5 32 Older adults without recommended preventive care 17 6 28 Children ages 19–35 months without all recommended vaccines 9 27 15 Mortality amenable to health care 34 7 10 Infant mortality, deaths per 1,000 live births 30 12 9 Adults with poor health-related quality of life 16 10 25 Adults who smoke 18 6 27 Adults who are obese 13 5 33 Adults who have lost six or more teeth 24 11 16 Notes: This exhibit measures indicator change over the two most recent years of data available. See Appendix A1 for baseline and current data years for each indicator. Trend data are not available for all indicators. Improvement indicates that the equity gap between states' vulnerable population and the U.S. average narrowed and that the rate among the states' vulnerable population improved. Worsening indicates that the equity gap between states' vulnerable population and the U.S. average widened and that the rate among the states' vulnerable population got worse. The "no change" category includes the number of states where the vulnerable group rate remained the same or changed but without a narrowing or widening in the gap with the U.S. average rate. It also includes the number of states without sufficient data for the vulnerable population to assess change over time. 17 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org looking toward the future Access and Affordability Gains reported by the scorecard likely reflect the influence of public policy— most noticeably, the role of the Affordable Care Act in expanding health insurance coverage—as well as public and private initiatives at the national, state, and community levels. States have many opportunities to widen these gains in various ways—purchasing health care for low-income Medicaid populations and state employees, establishing rules that guide health care and insurance markets, setting strategy for health information technology and prevention and exchange, supporting public health, and acting as conveners and collaborators treatment in improvement with other health care stakeholders. It will be important to continue tracking health system performance as health reforms are implemented, paying close attention to states that are expanding Medicaid and participating in other reforms. In addition, states can help to ensure that proven practices are fully adopted. For example, the stagnation and decline in rates of adult preventive care suggests an opportunity to implement evidence-based clinical and community-based interventions recommended by Avoidable the U.S. Preventive Services Task Force.10 Hospital Use The scorecard’s findings remind us that where you live matters. The sobering and Cost truth is that residents of certain states realize greater benefits from their health care systems than do those in other states. It doesn’t have to be this way. By acknowledging that access to care is the foundation of a high-performing health system and by focusing on the needs of low-income and other vulnerable populations, all states can safeguard and promote the health of their residents. All states can strive through policy and leadership to enhance patient care experiences, improve health outcomes, and lower health care spending.11 healthy lives Only by aiming high can the U.S. reach its potential as a nation where geography is not destiny, and where everyone, everywhere, has the opportunity to live a long and healthy life. equity The following principles guided the development of the scorecard: Methods Performance Metrics. The 42 performance metrics selected for this report span the health care system, representing important dimensions of care. Where possible, indicators align with those used in previous state scorecards. Since earlier versions of the scorecard, several indicators have been dropped either because all states improved to the point where no meaningful The Commonwealth Fund’s Scorecard on State Health System variations existed (e.g., hospital quality process-of-care measures) or the data Performance, 2015 Edition, evaluates 42 key indicators grouped into to construct the measures were no longer available. Several new indicators five dimensions (Appendix Exhibit A1): were added to the scorecard series starting in 2014, including measures of premature death, out-of-pocket spending on medical care relative to income, and potentially avoidable emergency department use. Access and Affordability (six indicators): includes rates of insurance coverage for children and adults, as well as individuals’ out-of-pocket expenses for medical care and cost- Measuring Change over Time. We were able to construct a time series for related barriers to receiving care. 36 of 42 indicators. Four scorecard indicators derived from the National Survey of Children’s Health could not be updated because the survey is Prevention and Treatment (16 indicators): includes conducted only every four years; a fifth indicator (Medicare beneficiaries’ measures of receiving preventive care and the quality of ratings of provider communication) did not have a comparable baseline care in ambulatory, hospital, and long-term care and data point in the time period measured in this scorecard. postacute settings. There were generally one to two years between indicators’ baseline and current year data observation, though the starting and ending points Potentially Avoidable Hospital Use and Cost depended on data availability. We chose this short time horizon so as to (nine indicators): includes indicators of hospital use that capture the immediate effects of changes relative to the policy and delivery might have been reduced with timely and effective care system environment, such as recent coverage expansions under the management and follow-up care, as well as estimates of Affordable Care Act, and other reforms as they are or may be enacted and per-person spending among Medicare beneficiaries and the implemented in the future. cost of employer-sponsored insurance. One indicator, hospital admissions for ambulatory care–sensitive conditions, We considered a change in an indicator’s value between the historical and reported separately for two distinct age groups. current year data points to be meaningful if it was at least one-half (0.5) of a standard deviation larger than the indictor’s combined distribution over Healthy Lives (11 indicators): includes indicators that the two time points—a common approach in social science research. measure premature death and health risk behaviors. T o assess change over time in the Equity dimension, we count how often the equity gap (described above) narrowed across indicators for each Equity: The scorecard evaluates differences in performance state during the time period measured by this scorecard. Within the race/ on 33 equity indicators associated with patients’ income ethnicity Equity subdimension, we evaluate trend data for an indicator only level (18 indicators) or race or ethnicity (15 indicators) that when there was comparable historical data on the racial/ethnic group with span the other four dimensions of performance. The data the largest equity gap in the most current assessment period. We consider available for some equity indicators, such as childhood improvement to have occurred in an equity indicator only if the equity gap vaccinations, may represent a different time point from that narrowed and health care for the states’ most-vulnerable group improved. used in the corresponding main scorecard indicator. For each state, health system performance on each equity indicator Data Sources. Indicators draw from publicly available data sources, as it pertains to low-income populations (under 200% of the including government-sponsored surveys, registries, publicly reported federal poverty level) and racial or ethnic minority groups quality indicators, vital statistics, mortality data, and administrative (black or other race or Hispanic ethnicity) is compared with databases. The most current data available were used in this report the national average. The resulting difference in performance whenever possible. Appendix Exhibits A1 and H1 provides detail on the is the “equity gap,” which forms the basis of our state data sources and time frames. rankings for this dimension. To support more comprehensive assessment of disparities, the 2015 scorecard expanded Scoring and Ranking Methodology. The scoring method follows previous the number of indicators evaluated in the equity dimension; state scorecards. States are first ranked from best to worst on each of the hence, the 2015 equity rankings are not strictly comparable to 42 performance indicators. We averaged rankings for indicators within earlier scorecards. each dimension to determine a state’s dimension rank and then averaged dimension rankings to determine overall ranking. This approach gives each dimension equal weight, and within dimensions it weights indicators equally. As in previous scorecards, if historical data were not available for a particular indicator in the baseline period, the most current year of data available was used as a substitute ensuring that ranks in each time period were based on the same number of indicators and as similar as possible. 19 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org NOTES 1. scorecard measures the percent of adults age 50 and older who have received all of the following: The sigmoidoscopy or colonoscopy in the past 10 years or a fecal occult blood test in the past two years; a mammogram in the past two years (women only); a Pap smear in the past three years (women only); and a flu shot in the past year and a pneumonia vaccine ever (age 65 and older only). 2. T. Hawley, J. A. Earp, M. O’Malley et al., “The Role of Physician Recommendation in Women’s Mammography S. Use: Is It a 2-Stage Process?” Medical Care, April 2000 38(4):392–403. 3. H. Ellenbecker, L. Samia, M. J. Cushman et al., “Chapter 13. Patient Safety and Quality in Home Health Care,” C. in Patient Safety and Quality: An Evidence-Based Handbook for Nurses, R. G. Hughes, editor (Rockville, Md.: Agency for Healthcare Research and Quality, April 2008). 4. Food and Drug Administration, “FDA Recommends Against the Continued Use of Propoxyphene,” U.S. Safety Announcement, Nov. 19, 2010; U.S. Food and Drug Administration, “Xanodyne Agrees to Withdraw Propoxyphene from the U.S. Market,” News Release, Nov. 19, 2010; and J. Driessen, S. H. Baik, Y. Zhang, “Explaining Improved Use of High-Risk Medications in Medicare Between 2007 and 2011,” Journal of the American Geriatrics Society (forthcoming). 5. Rice, “CMS Targets Nursing Homes’ Overuse of Antipsychotic Drugs,” Modern Healthcare, Sept. 22, 2014; U.S. S. General Accounting Office, Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use Among Older Adults in Nursing Homes, But Should Expand Efforts to Other Settings (Washington, D.C.: GAO, Jan. 30, 2015). 6.Centers for Medicare and Medicaid Services, “Readmissions Reduction Program,” Nov. 16, 2015; and M. Laderman, S. Loehrer, and D. McCarthy, “The Effect of Medicare Readmissions Penalties on Hospitals’ Efforts to Reduce Readmissions: Perspectives from the Field,” The Commonwealth Fund Blog, Feb. 26, 2013; and C. Boccuti and G. Casillas, Aiming for Fewer Hospital U-Turns: The Medicare Hospital Readmission Reduction Program (Menlo Park, Calif.: The Henry J. Kaiser Family Foundation, Jan. 29, 2015). 7. Mechanic, “Post-Acute Care: The Next Frontier for Controlling Medicare Spending,” New England Journal of R. Medicine, Feb. 20, 2014 370(8):692–694. 8. Loehrer, D. McCarthy, and E. Coleman, “Cross-Continuum Collaboration in Health Care: Unleashing the S. Potential,” Population Health Management, Oct. 2015 18(5):317–19; J. G. Ouslander and R. A. Berenson, “Reducing Unnecessary Hospitalizations of Nursing Home Residents,” New England Journal of Medicine, Sept. 29, 2011 365(13):1165–67; and J. G. Ouslander, G. Lamb, R. Tappen et al., “Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project,” Journal of the American Geriatrics Society, April 2011 59(4):745–53. 9.National spending estimates described here come from the CMS Office of the Actuary, National Health Statistics Group, Historic National Health Expenditure Tables, 2013. These national estimates account for all spending for all Medicare beneficiaries; they differ from the U.S. per-beneficiary spending estimates reported elsewhere in the scorecard, specifically in Appendix Exhibits A2 and E3. The latter estimates come from the CMS Office of Enterprise Data and Analytics and are restricted to beneficiaries age 65 and older, and exclude prescription drug spending.    10. K. Ockene, E. A. Edgerton, S. M. Teutsch et al., “Integrating Evidence-Based Clinical and Community Strategies J. to Improve Health,” American Journal of Preventive Medicine, March 2007 32(3):244–252. 11. Silow-Carroll and G. Moody, Lessons from High- and Low-Performing States for Raising Overall Health System S. Performance (New York: The Commonwealth Fund, May 2011). 20 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org about the authors Douglas McCarthy, M.B.A., is senior research director for The Commonwealth Fund, where he oversees the Fund’s scorecard project, conducts case-study research on delivery system reforms and breakthrough opportunities, and serves as a contributing editor to the Fund’s bimonthly newsletter, Transforming Care. His 30-year career has spanned research, policy, operations, and consulting roles for government, corporate, academic, nonprofit, and philanthropic organizations. He has authored and coauthored reports and peer-reviewed articles on a range of health care–related topics, including more than 50 case studies of high-performing organizations and initiatives. Mr. McCarthy received his bachelor’s degree with honors from Yale College and a master’s degree in health care management from the University of Connecticut. During 1996– 1997, he was a public policy fellow at the Hubert H. Humphrey School of Public Affairs at the University of Minnesota. David C. Radley, Ph.D., M.P.H., is senior scientist for The Commonwealth Fund’s Tracking Health System Performance initiative, working on the scorecard project. Dr. Radley and his team develop national, state, and substate regional analyses on health care system performance and related insurance and care system market structure analyses. Previously, he was associate in domestic health policy for Abt Associates, with responsibility for a number of projects related to measuring long-term care quality and evaluating health information technology initiatives. Dr. Radley received his Ph.D. in health policy from the Dartmouth Institute for Health Policy and Clinical Practice, and holds a B.A. from Syracuse University and an M.P.H. from Yale University. Susan L. Hayes, M.P.A., is senior research associate for The Commonwealth Fund’s Tracking Health System Performance initiative. In this role she supports the scorecard project, actively participating in the selection/development, research, and analysis of national, state, local, and special-population-level health system performance measures, and coauthoring scorecard reports and related publications. Ms. Hayes holds an M.P.A. from New York University’s Wagner School of Public Service, where she won the Martin Dworkis Memorial Award for academic achievement and public service. She graduated from Dartmouth College with an A.B. in English and began a distinguished career in journalism, working as an editorial assistant at PC Magazine and a senior editor at National Geographic Kids and later at Woman’s Day magazine. Following that period, Ms. Hayes was a freelance health writer and a contributing editor to Parent & Child magazine and cowrote a book on raising bilingual children with a pediatrician at Tufts Medical Center. 21 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org acknowledgments We owe our sincere appreciation to all of the researchers who developed indicators and conducted data analyses for this Scorecard. These include: Ashish Jha, M.D., M.P.H. and Jie Zheng, Ph.D., Harvard School of Public Health; Sherry Glied, Ph.D., and Claudia Solís-Román, New York University Robert F. Wagner Graduate School of Public Service; Vincent Mor, Ph.D., Denise Tyler, Ph.D., and Zhanlian Feng, Ph.D., Brown University; Yuting Zhang, Ph.D., and Seo Hyon Baik, Ph.D., University of Pittsburgh, and Ernest Moy, M.D., M.P.H., Agency for Healthcare Research and Quality (AHRQ). We would also like to thank the following Commonwealth Fund staff: David Blumenthal, Donald Moulds, Sara Collins, Eric Schneider, and Rachel Nuzum for providing constructive guidance throughout; and the Fund’s communications team, including Barry Scholl, Chris Hollander, Deborah Lorber, Mary Mahon, Christine Haran, Josh Tallman, Jen Wilson, and Paul Frame, for their guidance, editorial and production support, and public dissemination efforts. Finally, the authors wish to acknowledge the Institute for Healthcare Improvement for its support of the research unit, which enabled the analysis and development of the report. 22 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit A1. State Scorecard Data Years and Databases Indicator Past year Current year Database Access and Affordability 1 Adults ages 19–64 uninsured 2013 2014 ACS PUMS 2 Children ages 0–18 uninsured 2013 2014 ACS PUMS 3 Adults who went without care because of cost in past year 2013 2014 BRFSS 4 Individuals under age 65 with high out-of-pocket medical costs relative to their annual household income —a 2013–14 CPS ASEC 5 At-risk adults without a routine doctor visit in past two years 2013 2014 BRFSS 6 Adults without a dental visit in past year 2012 2014 BRFSS Prevention and Treatment 7 Adults with a usual source of care 2013 2014 BRFSS 8 Adults ages 50 and older who received recommended screening and preventive care 2012 2014 BRFSS 9 Children with a medical home —a 2011/12 NSCH 10 Children with a medical and dental preventive care visit in the past year —a 2011/12 NSCH 11 Children with emotional, behavioral, or developmental problems who received needed mental health care in the past year —a 2011/12 NSCH 12 Children ages 19–35 months who received all recommended doses of seven key vaccines 2013 2014 NIS 13 Medicare beneficiaries who received at least one drug that should be avoided in the elderly 2011 2012 5% Medicare enrolled in Part D Medicare beneficiaries with dementia, hip/pelvic fracture, or chronic renal failure who received a prescription drug 14 2011 2012 5% Medicare enrolled in Part D that is contraindicated for that condition Medicare fee-for-service patients whose health provider always listens, explains, shows respect, and spends enough CAHPS (via AHRQ National Healthcare 15 —a 2013 time with them Quality Report) 16 Risk-adjusted 30-day mortality among Medicare beneficiaries hospitalized for heart attack, heart failure, or pneumonia 07/2009–06/2012 07/2010–06/2013 CMS Hospital Compare 17 Hospitalized patients given information about what to do during their recovery at home 2012 2013 HCAHPS (via CMS Hospital Compare) Hospitalized patients who reported hospital staff always managed pain well, responded when needed help to get to 18 2012 2013 HCAHPS (via CMS Hospital Compare) bathroom or pressed call button, and explained medicines and side effects 19 Home health patients who get better at walking or moving around 2013 2014 OASIS (via CMS Home Health Compare) 20 Home health patients whose wounds improved or healed after an operation 2013 2014 OASIS (via CMS Home Health Compare) 21 High-risk nursing home residents with pressure sores 2013 2014 MDS (via CMS Nursing Home Compare) 22 Long-stay nursing home residents with an antipsychotic medication 2013 2014 MDS (via CMS Nursing Home Compare) Avoidable Hospital Use and Cost HCUP (via AHRQ National Healthcare 23 Hospital admissions for pediatric asthma, per 100,000 children 2011 2012 Quality Report) Hospital admissions among Medicare beneficiaries for ambulatory care–sensitive conditions, ages 65–74, and age 75 CCW (via CMS Geographic Variation 24 2012 2013 and older per 1,000 beneficiaries Public Use File) CCW (via CMS Geographic Variation 25 Medicare 30-day hospital readmissions, rate per 1,000 beneficiaries 2012 2013 Public Use File) 26 Short-stay nursing home residents readmitted within 30 days of hospital discharge to nursing home 2010 2012 MedPAR, MDS 27 Long-stay nursing home residents hospitalized within a six-month period 2010 2012 MedPAR, MDS 28 Home health patients also enrolled in Medicare with a hospital admission 2013 10/2013–9/2014 OASIS (via CMS Home Health Compare) 29 Potentially avoidable emergency department visits among Medicare beneficiaries, per 1,000 beneficiaries 2012 2013 5% Medicare SAF 30 Total single premium per enrolled employee at private-sector establishments that offer health insurance 2013 2014 MEPS CCW (via CMS Geographic Variation 31 Total Medicare (Parts A & B) reimbursements per enrollee 2012 2013 Public Use File) Healthy Lives 32 Mortality amenable to health care, deaths per 100,000 population 2010–11 2012–13 CDC NVSS: Mortality Restricted Use File 33 Years of potential life lost before age 75 2012 2013 CDC NVSS: WISQARS 34 Breast cancer deaths per 100,000 female population 2012 2013 CDC NVSS: WONDER 35 Colorectal cancer deaths per 100,000 population 2012 2013 CDC NVSS: WONDER 36 Suicide deaths per 100,000 population 2012 2013 CDC NVSS: WONDER 37 Infant mortality, deaths per 1,000 live births 2012 2013 CDC NVSS: WONDER 38 Adults ages 18–64 who report fair/poor health or activity limitations because of physical, mental, or emotional problems 2013 2014 BRFSS 39 Adults who smoke 2013 2014 BRFSS 40 Adults ages 18–64 who are obese (BMI >= 30) 2013 2014 BRFSS 41 Children ages 10–17 who are overweight or obese (BMI >= 85th percentile) —a 2011/12 NSCH 42 Percent of adults ages 18–64 who have lost six or more teeth because of tooth decay, infection, or gum disease 2012 2014 BRFSS Note: (a) Previous data not available or its definition is not comparable over time. 23 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit A2. List of 42 Indicators in the State Scorecard on Health System Performance Data Years Represented U.S. Average Rate Range of State Performance 2015 Scorecard 2015 2015 2015 Indicator Baselinea Scorecard Baselinea Scorecard Baselinea Scorecard Best State(s)b Access and Affordability 1 Adults ages 19–64 uninsured 2013 2014 20 16 * 5–30 5–26 MA 2 Children ages 0–18 uninsured 2013 2014 8 6* 2–14 2–12 MA 3 Adults who went without care because of cost in the past year 2013 2014 16 14 * 7–22 7–19 ND 4 Individuals with high out-of-pocket medical spending —c 2013-14 —c 15 —c 10–22 MD 5 At-risk adults without a doctor visit 2013 2014 14 13 7–23 6–22 RI 6 Adults without a dental visit in past year 2012 2014 15 16 10–20 11–20 SD, VT Prevention and Treatment 7 Adults with a usual source of care 2013 2014 76 77 65–88 65–89 MA 8 Older adults with recommended preventive care 2012 2014 42 40 * 34–52 32–48 CT 9 Children with a medical home —c 2011/12 —c 54 —c 45–69 VT 10 Children with a medical and dental preventive care visit in the past year —c 2011/12 —c 68 —c 56–81 VT 11 Children who received needed mental health care in the past year —c 2011/12 —c 61 —c 40–86 ND 12 Children ages 19–35 months with all recommended vaccines 2013 2014 70 72 57–82 63–85 ME 13 Elderly patients who received a high-risk prescription drug 2011 2012 20 17 * 12–29 9–24 MA 14 Elderly patients who received a contraindicated prescription drug 2011 2012 23 21 * 14–29 13–28 ME, RI 15 Medicare patients experienced good communication with provider —c 2013 —c 76 —c 72–80 LA 07/2009– 07/2010– 16 Hospital 30-day mortality 13.1 12.6 * 12.1–14.0 11.8–13.6 DE, MA 06/2012 06/2013 17 Hospital discharge instructions for home recovery 2012 2013 85 86 78–89 78–90 UT 18 Patient-centered hospital care 2012 2013 67 68 59–73 58–72 LA, ME, NE, SD 19 Home health patients who get better at walking or moving around 2013 2014 61 63* 49–66 51–69 UT 20 Home health patients whose wounds healed after an operation 2013 2014 89 89 80–93 74–95 RI 21 High-risk nursing home residents with pressure sores 2013 2014 6 6 3–9 3–8 HI, ID 22 Nursing home residents with an antipsychotic medication 2013 2014 21 19 * 9–27 9–25 AK Avoidable Hospital Use and Cost 23 Hospital admissions for pediatric asthma, per 100,000 children 2011 2012 107 143 * 33–232 28–231 VT Medicare admissions for ambulatory care–sensitive conditions, ages 65–74 2012 2013 29 27 13–51 13–46 HI 24 Medicare admissions for ambulatory care–sensitive conditions, age 75 and older 2012 2013 70 66 41–100 36–95 HI 25 Medicare 30-day hospital readmissions, per 1,000 beneficiaries 2012 2013 34 30 12–55 10–48 HI 26 Short-stay nursing home residents with a 30-day readmission to the hospital 2010 2012 22 20 * 14–28 13–26 MT 27 Long-stay nursing home residents with a hospital admission 2010 2012 19 17 7–31 7–30 MN 10/2013- 28 Home health patients with a hospital admission 2013 16 16 14–18 13–17 AK 9/2014 Potentially avoidable ED visits among Medicare beneficiaries, per 1,000 29 2012 2013 188 181 131–248 127–251 HI beneficiaries 30 Health insurance premium for employer-sponsored single-person plans 2013 2014 $5,633 $5,859 * $4,197–$7,334 $4,392–$7,592 CA 31 Total Medicare (Parts A & B) reimbursements per enrollee 2012 2013 $8,854 $8,801 $5,399–$10,868 $5,421–$10,697 HI Healthy Lives 32 Mortality amenable to health care, deaths per 100,000 population 2010-11 2012-13 85 84 57–133 56–137 MN 33 Years of potential life lost before age 75 2012 2013 $6,412 $6,420 $4,892–$9,610 $4,963–$9,945 MN 34 Breast cancer deaths per 100,000 female population 2012 2013 21.4 20.8 15.7–31.1 15.5–29.8 HI 35 Colorectal cancer deaths per 100,000 population 2012 2013 14.9 14.6 10.7–19.4 10.9–19.8 UT 36 Suicide deaths per 100,000 population 2012 2013 12.6 12.6 5.7–29.6 5.8–23.7 DC 37 Infant mortality, deaths per 1,000 live births 2012 2013 6 6 4.2–8.9 4.2–9.6 MA Adults ages 18–64 who report fair/poor health or activity limitations because of 38 2013 2014 26 27 20–34 19–34 DC physical, mental, or emotional problems 39 Adults who smoke 2013 2014 18 17 10–27 9–26 UT 40 Adults ages 18–64 who are obese (BMI >= 30) 2013 2014 29 29 22–37 21–38 CO, DC 41 Children ages 10–17 who are overweight or obese (BMI >= 85th percentile) —c 2011/12 —c 31 —c 22–40 UT Percent of adults ages 18–64 who have lost six or more teeth because of tooth 42 2012 2014 10 10 6–23 6–22 UT decay, infection, or gum disease Notes: (a) The baseline period generally reflects the year prior to the time of observation for the latest year of data available. (b) Multiple states may be listed in the event of ties. (c) Previous data are not shown because of changes in the indicators’ definitions or data were not available. * Asterisks indicate change between baseline and current time periods of at least 0.5 standard deviations (see Scorecard Methodology). 24 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit A3. National cumulative impact if all states achieved top state rate Indicator If all states improved their performance to the level of the best-performing state for this indicator, then: Insured Adults 21,126,092 more adults (ages 19–64) would be covered by health insurance (public or private), and therefore would be more likely to receive health care when needed. Insured Children 3,124,744 more children (ages 0–18) would be covered by health insurance (public or private), and therefore would be more likely to receive health care when needed. High Out-of-Pocket Medical Spending 11,636,543 fewer individuals would be burdened by high out-of-pocket spending on medical care. Went Without Care Because of Cost 16,957,363 fewer adults (age 18 and older) would go without needed health care because of cost. Adult Usual Source of Care 29,069,764 more adults (age 18 and older) would have a usual source of care to help ensure that care is coordinated and accessible when needed. Older Adult Preventive Care 8,691,519 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. Children with a Medical Home 11,087,987 more children (ages 0–17) would have a medical home to help ensure that care is coordinated and accessible when needed. Children with Preventive Medical and Dental Visits 9,609,589 more children (ages 0–17) would receive annual preventive medical and dental care visits each year. Medicare Received a High-Risk Drug 1,174,142 fewer Medicare beneficiaries would receive an inappropriately prescribed medication. Preventable Hospital Admissions Among Children 85,008 fewer children ages 2 to 17 would be hospitalized for asthma exacerbations. Hospital Readmissions 152,166 fewer hospital readmissions would occur among Medicare beneficiaries (age 65 and older). Potentially Avoidable Emergency 1,425,210 fewer emergency department visits for nonemergent or primary care–treatable conditions would Department Visits occur among Medicare beneficiaries. Mortality Amenable to Health Care 83,707 fewer premature deaths (before age 75) might occur from causes that are potentially treatable or preventable with timely and appropriate health care. Breast Cancer Deaths 8,552 fewer women would die from breast cancer. Colon Cancer Deaths 11,698 fewer individuals would die from colon cancer. Suicides 21,499 fewer individuals might take their own lives. Infant Mortality 7,078 more infants might live to see their first birthday. Adults Who Smoke 19,379,843 fewer adults would smoke, reducing their risk of lung and heart disease. Adults Who Are Obese 15,700,326 fewer adults would be obese, with body weights that increase their risk for disease and long-term complications. Children Who Are Overweight or Obese 3,019,159 fewer children (ages 10–17) would be overweight or obese, thus reducing the potential for poor health as they transition into adulthood. Adults with Tooth Loss 7,850,163 fewer adults (ages 18–64) would have lost six or more teeth to decay, infection, or gum disease. 25 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit B1. Summary of State Rankings in Current and Previous Scorecards 2015 Scorecard Ranks Overall 2014 Prevention Avoidable Ranking in the Scorecard Access and Treatment Use and Cost Healthy Lives Equity Baseline Time Overall State Overall Rank Dimension Dimension Dimension Dimension Dimension Perioda Rankb Alabama 47 32 37 46 46 42 40 46 Alaska 32 44 37 10 32 29 33 31 Arizona 33 43 47 10 29 24 35 36 Arkansas 49 44 47 38 49 51 49 50 California 23 30 37 14 7 22 25 26 Colorado 8 26 9 5 2 11 11 12 Connecticut 5 5 9 28 2 3 6 6 Delaware 15 9 9 24 33 14 12 10 District of Columbia 20 7 21 45 22 9 23 21 Florida 37 40 37 33 22 31 38 41 Georgia 46 41 45 28 39 45 45 45 Hawaii 3 11 18 1 6 1 1 5 Idaho 25 46 31 3 17 22 22 31 Illinois 26 19 21 44 22 24 31 26 Indiana 43 34 34 36 42 47 40 43 Iowa 9 7 9 18 16 15 7 10 Kansas 28 23 16 31 27 36 26 23 Kentucky 40 28 20 49 44 45 46 42 Louisiana 48 38 43 50 48 44 48 48 Maine 11 16 1 21 29 15 8 7 Maryland 18 5 14 42 20 13 18 17 Massachusetts 4 1 2 31 4 2 4 2 Michigan 31 15 16 38 38 31 29 26 Minnesota 1 3 8 8 1 9 1 1 Mississippi 51 48 47 51 51 49 51 51 Missouri 36 33 21 38 40 28 37 34 Montana 28 39 31 5 22 36 29 29 Nebraska 13 23 13 14 14 20 14 17 Nevada 43 50 51 18 36 39 46 46 New Hampshire 5 9 4 18 7 5 5 2 New Jersey 20 21 21 36 12 17 21 15 New Mexico 33 46 45 10 34 20 34 36 New York 13 14 28 26 13 5 15 19 North Carolina 37 30 31 26 36 43 36 36 North Dakota 26 25 19 22 27 36 18 14 Ohio 33 16 21 38 41 41 31 31 Oklahoma 50 48 44 46 46 49 50 49 Oregon 15 28 36 2 14 11 24 24 Pennsylvania 20 12 7 33 34 19 15 22 Rhode Island 5 4 3 22 10 7 8 9 South Carolina 40 41 28 24 43 48 40 36 South Dakota 15 22 14 8 29 17 18 12 Tennessee 43 34 37 42 44 39 38 40 Texas 40 51 50 33 22 31 40 44 Utah 18 36 28 5 4 24 12 19 Vermont 1 2 4 13 9 3 1 2 Virginia 23 19 21 28 20 24 26 24 Washington 10 16 37 4 10 8 15 15 West Virginia 39 26 21 48 50 31 40 34 Wisconsin 11 13 4 14 18 29 8 7 Wyoming 28 36 34 14 18 35 26 29 Notes: (a) The baseline period generally reflects the year prior to the time of observation for the latest year of data available. (b) The 2014 scorecard ranking is not based on the same set of indicators used to calculate the 2015 scorecard and 2015 scorecard baseline rankings. Rather, it represents the time period evaluated in the 2014 scorecard, generally encompassing the years 2010–2012. The 2015 scorecard added several variables to the equity dimension. 26 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit B2. Summary of Indicator Rankings by State No. of No. of indicators indicators No. of No. of Overall scored Top 5 Top 2nd 3rd Bottom Bottom 5 with trend indicators indicators Net Rank State (of 42) States Quartile Quartile Quartile Quartile States (of 36) improved worsened change 47 Alabama 41 1 4 4 12 21 12 35 7 5 2 32 Alaska 39 6 9 11 5 14 9 34 11 5 6 33 Arizona 42 2 6 12 12 12 3 36 12 3 9 49 Arkansas 42 0 2 7 9 24 16 36 11 2 9 23 California 42 8 16 9 12 5 2 36 11 2 9 8 Colorado 42 14 19 16 5 2 0 36 9 1 8 5 Connecticut 42 10 24 9 7 2 1 36 8 4 4 15 Delaware 41 4 14 9 16 2 2 35 8 3 5 20 District of Columbia 38 10 15 5 9 9 8 32 12 2 10 37 Florida 42 2 4 16 11 11 7 36 10 1 9 46 Georgia 42 0 1 11 16 14 4 36 11 2 9 3 Hawaii 40 16 25 8 4 3 2 34 6 4 2 25 Idaho 41 7 16 10 2 13 4 35 8 4 4 26 Illinois 42 0 8 13 14 7 3 36 8 2 6 43 Indiana 42 0 0 10 22 10 0 36 6 3 3 9 Iowa 42 8 14 17 11 0 0 36 9 2 7 28 Kansas 42 1 5 18 18 1 1 36 10 1 9 40 Kentucky 42 1 3 9 12 18 11 36 13 3 10 48 Louisiana 42 2 4 5 6 27 21 36 16 3 13 11 Maine 42 8 20 12 7 3 0 36 6 3 3 18 Maryland 42 5 14 12 13 3 4 36 11 2 9 4 Massachusetts 42 22 26 7 6 3 1 36 11 4 7 31 Michigan 42 1 8 14 12 8 2 36 8 2 6 1 Minnesota 42 17 31 6 2 3 3 36 8 4 4 51 Mississippi 41 3 4 1 5 31 28 35 11 4 7 36 Missouri 42 0 3 10 24 5 1 36 9 1 8 28 Montana 42 4 12 12 9 9 1 36 10 3 7 13 Nebraska 42 7 15 17 7 3 1 36 5 2 3 43 Nevada 42 2 7 5 10 20 11 36 12 3 9 5 New Hampshire 41 10 20 17 2 2 0 35 8 4 4 20 New Jersey 42 6 16 9 6 11 7 36 9 2 7 33 New Mexico 41 2 7 10 9 15 4 35 9 3 6 13 New York 42 4 12 13 11 6 4 36 8 1 7 37 North Carolina 42 1 5 10 19 8 1 36 10 1 9 26 North Dakota 40 9 13 7 12 8 3 35 11 5 6 33 Ohio 42 0 1 18 13 10 1 36 7 2 5 50 Oklahoma 42 1 3 3 12 24 11 36 14 2 12 15 Oregon 42 8 15 15 6 6 3 36 11 3 8 20 Pennsylvania 41 4 11 14 13 3 1 35 5 3 2 5 Rhode Island 41 11 22 13 4 2 0 36 14 3 11 40 South Carolina 42 0 4 13 9 16 3 36 6 1 5 15 South Dakota 41 8 15 14 6 6 1 36 9 2 7 43 Tennessee 42 0 1 8 14 19 7 36 13 0 13 40 Texas 42 3 4 7 13 18 11 36 6 4 2 18 Utah 42 14 18 8 8 8 3 36 5 2 3 1 Vermont 41 17 23 12 5 1 1 35 8 4 4 23 Virginia 42 1 3 21 15 3 2 36 6 2 4 10 Washington 42 4 18 13 5 6 2 36 11 3 8 39 West Virginia 42 3 5 9 11 17 15 36 11 5 6 11 Wisconsin 42 9 15 17 10 0 0 36 5 3 2 28 Wyoming 41 4 13 11 7 10 6 35 10 7 3 Notes: Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. Ambulatory care–sensitive conditions among Medicare beneficiaries are counted as a single indicator in tallies of improvement. 27 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit C1. Access and Affordability: Dimension and Indicator Ranking g Overall performance, 2015 in it st nd vis co pe ) ) 18 or 64 Top quartile of ls ct 0– 9– ica se ar do es s1 au ye Second quartile ed ta ag ec ge st tm ou n( eb pa Third quartile (a th ke re ar lt s in wi oc ld tc Bottom quartile it du i f-p ts ch vis ou a ul t-o ed ed th ad al Data not available wi nt ur ur ou sk de ns ns t gh -ri en i i No Un Un At Hi W 1 Massachusetts 2 Vermont 3 Minnesota 4 Rhode Island 5 Connecticut 5 Maryland 7 District of Columbia 7 Iowa 9 Delaware 9 New Hampshire 11 Hawaii 12 Pennsylvania 13 Wisconsin 14 New York 15 Michigan 16 Maine 16 Ohio 16 Washington 19 Illinois 19 Virginia 21 New Jersey 22 South Dakota 23 Kansas 23 Nebraska 25 North Dakota 26 Colorado 26 West Virginia 28 Kentucky 28 Oregon 30 California 30 North Carolina 32 Alabama 33 Missouri 34 Indiana 34 Tennessee 36 Utah 36 Wyoming 38 Louisiana 39 Montana 40 Florida 41 Georgia 41 South Carolina 43 Arizona 44 Alaska 44 Arkansas 46 Idaho 46 New Mexico 48 Mississippi 48 Oklahoma 50 Nevada 51 Texas 28 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit C2. Access and Affordability: Dimension Ranking and Indicator Rates Adults who went Individuals Adults Children without care with high At-risk adults Adults without ages 19–64 ages 0–18 Uninsured because of cost in out-of-pocket without a a dental visit in uninsured uninsured ages 0–64 the past year medical spending doctor visit past year 2013 2014 2013 2014 2013 2014 2013 2014 2013-14 2013 2014 2012 2014 United States 20% 16% * 8% 6% * 17% 13% * 16% 14% * 15% 14% 13% 15% 16% Alabama 20 18 5 4 16 14 * 16 17 16 12 12 18 18 Alaska 24 22 12 12 20 19 14 12 * 18 23 22 14 16 * Arizona 24 18 ** 13 10 ** 20 16 * 17 16 16 19 16 * 17 18 Arkansas 24 18 ** 6 5 19 14 ** 21 18 * 21 18 18 19 18 California 24 17 ** 8 6* 19 14 ** 16 14 * 13 17 15 * 16 17 Colorado 19 14 * 9 6 ** 16 12 * 15 13 * 15 18 17 16 15 Connecticut 13 9* 4 4 11 8* 12 11 13 10 11 11 12 Delaware 14 10 * 5 5 12 9* 12 11 13 9 10 12 14 * District of Columbia 8 7 -- -- 7 6 11 11 11 9 8 16 16 Florida 29 24 * 12 10 * 24 20 * 21 18 * 15 14 12 * 18 17 Georgia 26 22 * 10 8* 21 18 * 20 19 15 14 13 16 17 Hawaii 10 7* 3 3 8 6* 9 9 14 14 15 15 14 Idaho 23 19 * 9 8 19 15 * 16 16 22 21 20 13 15 * Illinois 18 14 * 5 4 14 11 * 14 12 * 13 14 13 15 16 Indiana 19 17 9 7* 16 14 * 16 15 16 17 17 15 15 Iowa 12 8* 5 3* 10 7* 10 9 15 14 12 * 12 13 Kansas 18 15 * 7 6 14 12 * 14 13 15 14 15 13 13 Kentucky 21 12 ** 6 5 17 10 ** 19 16 * 18 15 15 16 16 Louisiana 25 22 * 6 5 19 17 * 20 17 * 19 10 10 20 20 Maine 16 14 5 6 13 12 10 11 15 12 12 13 13 Maryland 14 11 * 5 4 11 9* 13 10 * 10 10 7* 13 15 * Massachusetts 5 5 2 2 4 4 9 8 11 7 7 11 12 Michigan 16 12 * 5 4 13 10 * 15 15 15 13 11 * 14 14 Minnesota 11 8* 6 4* 9 7* 10 9 12 12 11 11 13 * Mississippi 25 22 * 8 6* 20 17 * 22 19 * 20 15 14 19 20 Missouri 18 16 7 7 15 13 * 16 14 * 17 16 15 15 16 Montana 23 19 * 11 9* 20 16 * 14 12 * 19 19 17 * 17 16 Nebraska 15 13 6 5 12 11 13 12 15 18 17 15 16 Nevada 27 21 ** 14 10 ** 23 17 ** 17 17 18 15 17 * 20 19 New Hampshire 16 13 * 4 5 13 11 * 12 11 12 11 11 10 12 * New Jersey 19 16 * 6 5 15 13 * 15 14 13 10 9 15 16 New Mexico 28 21 ** 9 8 22 17 ** 18 17 16 17 18 18 18 New York 15 12 * 4 4 12 10 * 15 14 12 10 10 15 16 North Carolina 23 19 * 6 6 18 15 * 18 16 * 18 12 11 15 14 North Dakota 14 10 * 8 7 12 9* 7 7 17 17 17 15 16 Ohio 16 12 * 5 5 13 10 * 15 13 * 15 13 12 14 15 Oklahoma 25 21 * 11 9* 20 18 * 17 15 * 19 21 19 * 18 17 Oregon 21 14 ** 7 5* 17 12 ** 18 14 ** 20 20 16 ** 15 14 Pennsylvania 14 12 5 5 11 10 12 12 12 12 12 13 14 Rhode Island 17 10 ** 6 3 ** 14 8 ** 14 12 * 13 10 6 ** 12 12 South Carolina 23 20 * 7 6 18 16 * 19 18 17 16 15 18 18 South Dakota 17 13 * 7 8 14 12 * 10 10 16 14 16 * 11 11 Tennessee 20 17 * 6 5 16 14 * 18 16 * 22 11 12 17 18 Texas 30 26 * 13 12 24 21 * 19 18 17 15 16 18 20 * Utah 18 16 9 9 15 14 15 14 16 19 19 16 15 Vermont 10 7* -- -- 8 5* 9 9 12 11 12 11 11 Virginia 17 15 6 6 14 12 * 15 13 * 12 12 12 12 14 * Washington 20 13 ** 7 5* 16 11 ** 15 12 * 13 17 16 14 14 West Virginia 20 13 ** 5 3* 16 11 ** 18 17 17 12 9* 18 20 * Wisconsin 13 10 * 5 5 10 9 12 11 16 13 12 12 12 Wyoming 18 17 7 7 15 14 14 12 * 18 21 21 15 15 Change 39 16 42 21 13 9 States Improved 39 16 42 21 11 0 States Worsened 0 0 0 0 2 9 Notes: * denotes a change of at least 0.5 standard deviations; ** denotes a change of 1.0 standard deviation or more. -- Data not available. 29 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit D1. Prevention and Treatment: Dimension and Indicator Ranking Overall performance, 2015 r ea ty es as cin g ru ep Top quartile ac t nd i si th dv n ti o ev in ti o de y Second quartile ip ar re er ica en re cr d g ec ca ov te in ca es m un ec ti v alk l th ca le d m pr m ive Third quartile er di en co ea tw m ea sk in nt om ev re co lh sh -ri th ra tra ve pr all ta rh od wi gh te nd re Bottom quartile on en al fo re i th go et dp hi ts ou ac nt dm ca tb n an en ns da sw ed de ew e de e ar ed ge id io of t i o i th de om nc ive en th nd lc os es ct e iv e ee ho ica s w rie on y m ce lh tru rc la ta er n wh lit g ec dn om d w pe m ou pi re ica r ica ed t ta s om ns m en ru o r u n ts tio ts os ex ive 35 s c or ho ei ed ea ed ro tien ra en re ic sid re h n d wh al dh ym 9– er s ce sw rg so ing am ty m su pe ati th id n t ot re re ga a tio ts re ha s1 as h a wi da au o v tie nt hp no hp re rs ch e te ip n th isc ho sy om ge tie cr tie 0- su nu pr pa lts e p it en o v lt r a lt th wi th w nw l3 ld na m ea te e a pa es pa t ip h u -c es k wi re in n in ren ad pr -ris an ing ita ita or e h af e h nt ica re re re rly pr rly ts er tie sp sp ild ild ild ild rs m m gh ul th de de ed d Ho Ho Ho Ho Nu Ad Pa Ch Ch Ch Ch wi Hi Ol El El M 1 Maine 2 Massachusetts 3 Rhode Island 4 New Hampshire 4 Vermont 4 Wisconsin 7 Pennsylvania 8 Minnesota 9 Colorado 9 Connecticut 9 Delaware 9 Iowa 13 Nebraska 14 Maryland 14 South Dakota 16 Kansas 16 Michigan 18 Hawaii 19 North Dakota 20 Kentucky 21 District of Columbia 21 Illinois 21 Missouri 21 New Jersey 21 Ohio 21 Virginia 21 West Virginia 28 New York 28 South Carolina 28 Utah 31 Idaho 31 Montana 31 North Carolina 34 Indiana 34 Wyoming 36 Oregon 37 Alabama 37 Alaska 37 California 37 Florida 37 Tennessee 37 Washington 43 Louisiana 44 Oklahoma 45 Georgia 45 New Mexico 47 Arizona 47 Arkansas 47 Mississippi 50 Texas 51 Nevada 30 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit D2. Prevention and Treatment: Dimension Ranking and Indicator Rates Children with Children who Children a medical and received needed ages 19–35 Elderly patients Elderly patients Older adults with Children dental preventive mental health months with all who received a who received a Adults with a usual recommended with a care visit in the care in the recommended high-risk contraindicated source of care preventive care medical home past year past year vaccines prescription drug prescription drug 2013 2014 2012 2014 2011/12 2011/12 2011/12 2013 2014 2011 2012 2011 2012 United States 76% 77% 42% 40% * 54% 68% 61% 70% 72% 20% 17% * 23% 21% * Alabama 78 76 42 40 * 54 70 54 77 77 29 24 ** 29 28 Alaska 67 66 39 38 52 59 63 64 67 * 19 17 21 17 ** Arizona 68 72 * 34 37 * 46 65 60 65 66 19 17 18 18 Arkansas 77 78 34 35 55 62 67 57 66 ** 25 17 ** 26 23 * California 71 74 * 40 32 ** 45 65 63 69 78 ** 19 16 * 22 21 Colorado 76 76 44 42 * 55 70 65 69 73 * 19 16 * 19 18 Connecticut 85 84 47 48 58 79 65 78 73 ** 14 13 17 15 * Delaware 86 86 48 47 56 72 67 72 75 * 18 16 16 17 District of Columbia 76 75 44 43 50 77 59 77 71 ** 17 13 * 19 20 Florida 73 76 * 39 38 50 60 58 70 73 * 19 16 * 22 21 Georgia 72 71 46 42 ** 52 65 53 70 74 * 25 21 * 24 21 * Hawaii 85 85 44 45 57 73 58 66 74 ** 21 21 18 18 Idaho 72 71 35 33 * 57 59 56 70 66 * 22 16 ** 24 22 * Illinois 80 81 39 39 56 74 55 67 68 15 13 19 18 Indiana 80 80 37 36 58 69 58 69 66 * 20 17 * 22 21 Iowa 81 80 44 43 67 70 66 78 71 ** 15 12 * 19 17 * Kansas 78 80 43 39 ** 59 70 72 69 77 ** 20 15 ** 22 20 * Kentucky 78 79 40 44 ** 56 68 66 73 72 26 23 * 27 24 * Louisiana 74 74 40 40 56 67 40 69 73 * 28 24 * 26 23 * Maine 87 88 47 46 63 73 78 68 85 ** 13 12 14 13 Maryland 79 82 * 48 47 57 73 59 76 74 16 15 19 18 Massachusetts 88 89 52 47 ** 63 79 65 79 75 * 12 9* 16 15 Michigan 83 84 45 45 59 68 68 70 65 ** 16 14 20 19 Minnesota 73 76 * 46 45 61 60 72 74 71 * 13 10 * 17 15 * Mississippi 77 73 * 37 38 49 60 53 75 71 * 29 22 ** 27 26 Missouri 79 79 42 38 ** 62 65 63 68 70 20 16 * 23 21 * Montana 70 71 35 38 * 58 61 60 65 67 17 13 * 22 17 ** Nebraska 79 80 39 41 * 61 70 71 79 80 18 13 ** 21 21 Nevada 65 65 36 34 * 45 56 49 61 68 ** 21 17 * 20 18 * New Hampshire 88 85 * 48 46 * 67 79 66 75 80 ** 14 13 20 19 New Jersey 81 82 41 42 53 76 58 73 67 ** 15 15 20 18 * New Mexico 69 69 36 37 48 70 58 66 76 ** 22 18 * 23 21 * New York 81 81 44 43 53 73 64 72 71 13 12 18 17 North Carolina 73 76 * 46 45 55 67 54 72 81 ** 23 20 * 23 21 * North Dakota 73 71 37 39 * 62 61 86 72 71 14 11 * 16 14 * Ohio 81 80 41 39 * 57 71 66 62 68 ** 19 17 22 20 * Oklahoma 74 75 37 36 56 62 61 63 73 ** 27 22 ** 27 26 Oregon 74 77 * 39 39 57 63 66 67 65 19 16 * 19 17 * Pennsylvania 86 85 44 42 * 59 73 69 76 79 * 15 13 19 18 Rhode Island 84 86 46 47 60 76 66 82 76 ** 14 11 * 16 13 * South Carolina 76 77 42 41 54 64 50 67 73 ** 24 20 * 24 22 * South Dakota 76 75 41 44 * 62 59 64 74 76 13 10 * 18 15 * Tennessee 77 76 41 41 60 70 60 68 72 * 27 21 ** 26 24 * Texas 67 67 38 37 52 68 59 72 64 ** 23 19 * 23 22 Utah 72 71 40 41 64 61 49 75 71 * 21 18 * 26 23 * Vermont 87 87 47 44 * 69 81 78 67 72 ** 12 11 17 14 * Virginia 76 76 45 46 57 70 53 69 74 ** 20 17 * 21 20 Washington 72 75 * 43 43 59 72 54 71 67 * 19 16 * 19 17 * West Virginia 77 77 43 41 * 61 74 74 66 63 * 22 17 ** 22 20 * Wisconsin 81 81 43 43 66 68 65 73 71 13 11 16 15 Wyoming 69 69 36 34 * 59 65 67 70 64 ** 17 13 * 18 22 ** Change 10 21 38 35 28 States Improved 8 6 22 35 27 States Worsened 2 15 16 0 1 Notes: * denotes a change of at least 0.5 standard deviations; ** denotes a change of 1.0 standard deviation or more. 31 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit D2. Prevention and Treatment: Dimension Ranking and Indicator Rates (continued) Hospital Home health Medicare patients discharge Home health patients High-risk Nursing home experienced good instructions patients who get whose wounds nursing home residents with communication Hospital 30-day for home Patient-centered better at walking healed after residents with an antipsychotic with provider mortality recovery hospital care or moving around an operation pressure sores medication 07/09– 07/10– 2013 2012 2013 2012 2013 2013 2014 2013 2014 2013 2014 2013 2014 06/12 06/13 United States 76% 13.1% 12.6% ** 85% 86% 67% 68% 61% 63% * 89% 89% 6% 6% 21% 19% * Alabama 74 13.4 13.1 * 83 85 * 69 69 65 68 * 91 91 5 5 23 22 Alaska 76 14.0 13.1 ** 85 88 ** 67 70 ** 49 51 * 80 74 ** 6 4 ** 9 9 Arizona 74 13.3 12.5 ** 84 86 * 66 66 58 60 * 86 87 6 5* 21 19 * Arkansas 72 13.9 13.6 * 82 83 67 68 61 64 * 90 90 6 6 24 19 ** California 74 12.8 12.4 * 82 84 * 63 64 59 61 * 91 92 6 6 16 14 * Colorado 76 12.9 12.2 ** 87 88 69 70 62 64 * 90 89 4 4 18 18 Connecticut 77 13.2 12.4 ** 84 85 65 65 59 60 90 90 5 4* 22 20 * Delaware 79 12.4 11.8 ** 84 85 67 67 58 61 * 82 83 5 5 17 15 * District of Columbia 79 12.1 11.9 78 78 59 58 60 64 ** 90 91 9 8* 18 16 * Florida 76 13.2 12.6 ** 82 83 63 63 65 67 * 92 91 6 6 22 21 Georgia 76 13.2 12.9 * 83 84 66 66 61 64 * 90 90 7 7 22 20 * Hawaii 77 13.0 12.7 * 82 85 ** 68 69 55 59 ** 83 82 3 3 12 10 * Idaho 74 13.6 12.9 ** 88 88 70 70 63 65 * 91 92 4 3* 20 18 * Illinois 77 12.7 12.4 * 85 86 66 67 61 62 88 88 7 6* 23 22 Indiana 76 13.2 12.9 * 86 87 69 69 59 62 * 89 89 6 6 20 19 Iowa 75 13.0 12.9 86 88 * 69 69 62 64 * 88 88 4 4 19 19 Kansas 75 12.9 12.6 * 86 86 70 70 61 63 * 88 88 5 5 21 20 Kentucky 77 13.2 12.9 * 85 86 69 69 64 66 * 91 91 7 6* 22 21 Louisiana 80 13.3 13.0 * 84 86 * 71 72 60 62 * 92 91 9 8* 27 25 * Maine 77 13.5 12.7 ** 89 89 71 72 62 64 * 88 89 4 4 22 20 * Maryland 76 12.7 12.0 ** 84 85 62 61 63 65 * 89 90 7 7 17 16 Massachusetts 77 12.3 11.8 ** 87 87 67 67 63 66 * 92 92 5 5 22 20 * Michigan 75 12.8 12.4 * 87 87 69 68 61 64 * 87 87 6 6 15 14 Minnesota 78 12.7 12.3 * 87 88 70 71 57 59 * 85 84 4 4 16 14 * Mississippi 78 13.2 13.1 81 83 * 69 70 64 66 * 92 92 7 7 24 23 Missouri 77 13.2 12.7 ** 86 87 66 67 62 65 * 90 90 6 6 23 21 * Montana 77 12.7 12.6 83 85 * 67 67 56 60 ** 92 90 * 5 6* 19 18 Nebraska 79 13.3 13.0 * 87 88 71 72 59 62 * 83 84 4 4 22 21 Nevada 73 13.5 13.2 * 83 84 61 64 ** 60 62 * 91 91 7 7 22 21 New Hampshire 78 13.7 12.6 ** 88 88 70 69 59 60 87 87 4 4 22 19 * New Jersey 76 12.7 12.2 ** 81 82 62 63 63 65 * 90 90 8 7* 16 15 New Mexico 73 12.9 12.7 82 84 * 66 66 59 62 * 93 90 ** 6 6 19 17 * New York 75 13.0 12.5 ** 82 84 * 62 63 59 63 ** 89 89 8 8 19 18 North Carolina 76 13.3 13.0 * 86 87 68 69 61 62 90 89 7 7 16 15 North Dakota 73 12.8 12.2 ** 86 82 ** 65 70 ** 56 61 ** 87 89 * 4 4 18 18 Ohio 76 12.8 12.4 * 86 87 68 68 61 63 * 88 88 6 6 22 21 Oklahoma 76 13.1 12.7 * 83 85 * 69 70 60 62 * 91 91 8 8 22 21 Oregon 74 13.9 13.0 ** 85 86 67 68 56 59 * 89 90 7 6* 18 18 Pennsylvania 78 12.9 12.4 ** 85 86 66 67 63 65 * 87 87 6 5* 20 18 * Rhode Island 77 13.3 12.7 ** 85 86 66 67 63 65 * 93 95 * 6 5* 18 16 * South Carolina 77 13.4 13.0 * 85 86 69 69 64 65 92 91 6 6 17 16 South Dakota 77 13.0 12.5 ** 86 87 73 72 58 60 * 88 85 ** 5 5 18 18 Tennessee 75 13.2 13.0 84 85 68 68 63 64 90 89 5 5 25 23 * Texas 75 13.1 12.5 ** 84 86 * 69 69 56 57 88 87 7 7 27 25 * Utah 75 13.5 12.9 ** 89 90 69 70 66 69 * 92 91 5 5 23 21 * Vermont 75 13.9 13.1 ** 88 88 68 69 60 62 * 88 91 ** 5 5 21 19 * Virginia 75 13.3 12.9 * 85 86 65 66 63 64 90 90 6 6 21 18 * Washington 74 14.0 13.4 ** 86 87 66 66 56 58 * 88 88 6 6 20 18 * West Virginia 73 13.1 12.6 ** 84 85 66 67 63 64 91 90 7 6* 19 17 * Wisconsin 78 13.4 12.8 ** 88 89 71 71 59 62 * 87 88 5 4* 17 14 * Wyoming 74 12.9 12.5 * 87 88 68 69 58 58 88 86 * 4 4 18 16 * Change 45 14 3 41 8 15 27 States Improved 45 13 3 41 3 14 27 States Worsened 0 1 0 0 5 1 0 Notes: * denotes a change of at least 0.5 standard deviations; ** denotes a change of 1.0 standard deviation or more. 32 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit E1. Avoidable Hospital Use and Cost: Dimension and Indicator Ranking ve ve d Overall performance, 2015 re iti iti d so ns ns n io te on ts se se iss en us p e– e– Top quartile y dj r-s dm a a nc em a ar ar m th th x a ye ge la yc yc th rs wi wi Second quartile de plo er ta as bu or or ts m ts pi m -in em at er at ric ys en ee en os d ei ul ld bul Third quartile ns iat da esid sid ah ze ) r ge or bl 4 b io m do m n) ed wa f da di B re iss s, um ra an r a ith 30 r ar & re r p Bottom quartile oi in me n e 65 fo 5 fo m sw nd A t s av an i om ild fo pl m –7 ith ho ad ta rts es ns e 7 ns re isi lly nt ch s iss g h Data not available re 0 ion Pa ag io ag io n w ng on p tie t v tia io dm in iss s, iss rs ce ay io rsi lee e ( 00 ss pa en n l a urs pe an -d te on m on m 0, mi ,s iss nu ol ar lth 30 rtm po iti ad iti ad e- ur ita n nr ic 10 ad s, m y gl s sp tay ea r e ed ad ta nd re nd re re pa re in er l (p pita eh re rt-s pe l M co ica co ica ica de dica ho -s sin lth ng m ta ed ed ed s a o e Ho Ho He Sh To Lo M M M M 1 Hawaii 2 Oregon 3 Idaho 4 Washington 5 Colorado 5 Montana 5 Utah 8 Minnesota 8 South Dakota 10 Alaska 10 Arizona 10 New Mexico 13 Vermont 14 California 14 Nebraska 14 Wisconsin 14 Wyoming 18 Iowa 18 Nevada 18 New Hampshire 21 Maine 22 North Dakota 22 Rhode Island 24 Delaware 24 South Carolina 26 New York 26 North Carolina 28 Connecticut 28 Georgia 28 Virginia 31 Kansas 31 Massachusetts 33 Florida 33 Pennsylvania 33 Texas 36 Indiana 36 New Jersey 38 Arkansas 38 Michigan 38 Missouri 38 Ohio 42 Maryland 42 Tennessee 44 Illinois 45 District of Columbia 46 Alabama 46 Oklahoma 48 West Virginia 49 Kentucky 50 Louisiana 51 Mississippi 33 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit E2. Avoidable Hospital Use and Cost: Dimension Ranking and Indicator Rates Potentially Hospital Medicare Medicare Short-stay avoidable ED admissions admissions admissions Medicare 30- Medicare 30- nursing home Long-stay visits among for pediatric for ambulatory for ambulatory day hospital day hospital residents nursing home Home health Medicare asthma, care–sensitive care–sensitive readmissions, readmissions with a 30-day residents with patients with beneficiaries, per 100,000 conditions, ages conditions, age per 1,000 as a percent of readmission to a hospital a hospital per 1,000 children 65–74 75 and older beneficiaries admissions(a) the hospital admission admission beneficiaries 10/13– 2011 2012 2012 2013 2012 2013 2012 2013 2012 2013 2010 2012 2010 2012 2013 2012 2013 9/14 United States 107 143 * 29 27 70 66 34 30 18 17 22% 20% * 19% 17% 16% 16% 188 181 Alabama -- -- 38 34 * 82 75 * 39 34 * 17 16 22 22 21 21 17 17 192 184 Alaska 46 62 -- -- 52 49 29 26 14 14 -- -- -- -- 14 13 ** 205 203 Arizona 106 125 20 18 51 48 23 20 16 15 23 20 * 12 9* 15 15 178 171 Arkansas 64 81 35 31 * 83 78 42 36 * 18 16 25 25 27 26 17 17 185 177 California 87 96 21 20 55 53 24 21 18 17 23 22 21 20 15 15 167 163 Colorado 143 129 16 15 50 45 19 16 14 13 17 16 12 10 14 14 173 164 Connecticut 144 136 26 24 75 70 39 34 * 18 17 22 20 * 19 16 * 16 17 ** 189 189 Delaware -- -- 27 27 68 66 40 37 17 16 22 20 * 19 19 16 17 ** 159 159 District of Columbia -- -- 37 36 74 65 * 55 48 * 21 20 -- -- -- -- 18 17 ** 248 251 Florida 145 143 28 27 68 66 34 30 18 18 24 22 * 25 23 15 15 179 176 Georgia 88 97 31 29 73 68 33 29 17 16 23 21 * 20 19 16 16 201 188 * Hawaii 52 69 13 13 41 36 12 10 15 14 -- -- -- -- 14 15 ** 131 127 Idaho -- -- 17 16 45 42 17 16 13 13 14 14 12 11 14 14 162 159 Illinois 117 119 31 28 73 70 51 44 * 19 18 25 23 * 25 22 * 16 16 192 186 Indiana 105 102 35 32 77 73 40 34 * 17 16 21 20 20 19 16 16 200 192 Iowa 69 71 24 22 64 60 33 29 15 15 18 17 16 15 16 16 184 179 Kansas 144 160 27 25 71 66 37 33 16 15 21 19 * 20 20 17 17 173 169 Kentucky 167 152 51 46 * 100 95 50 42 * 19 19 23 22 24 24 18 17 ** 219 219 Louisiana 232 203 * 44 41 97 88 * 40 35 * 18 18 28 26 * 31 30 16 16 236 219 * Maine 72 76 26 26 65 61 31 28 16 15 18 17 14 12 16 16 233 217 * Maryland 132 137 29 28 69 66 49 43 * 19 18 26 22 ** 20 17 * 17 17 193 186 Massachusetts 182 141 * 30 28 80 76 41 36 * 18 17 22 19 * 17 14 * 16 17 ** 209 197 * Michigan 97 94 34 31 73 70 42 38 19 18 25 23 * 20 18 16 16 214 210 Minnesota 70 82 20 19 55 54 18 15 16 15 18 17 7 7 16 16 181 175 Mississippi -- -- 42 38 * 91 88 48 42 * 18 17 26 24 * 31 29 17 17 231 222 Missouri 150 161 31 30 73 69 37 33 17 17 22 22 21 20 16 16 197 190 Montana 65 77 21 19 -- 55 25 24 14 14 14 13 12 12 15 15 158 159 Nebraska 58 82 * 24 23 63 59 33 29 15 14 18 16 * 17 16 16 16 153 149 Nevada 98 112 25 23 60 55 26 23 18 17 25 23 * 20 20 15 15 165 158 New Hampshire -- -- 23 23 64 62 34 32 16 16 18 16 * 13 14 17 16 ** 192 175 * New Jersey 149 163 27 26 73 69 47 41 * 19 18 27 24 * 26 21 * 16 16 170 160 New Mexico -- -- 23 21 59 52 * 22 19 15 15 19 18 15 13 15 15 170 170 New York 221 231 29 26 73 69 36 31 * 20 19 26 23 * 19 17 17 16 ** 173 165 North Carolina 109 113 29 27 67 64 35 31 17 16 21 20 19 18 16 16 197 192 North Dakota -- -- 24 22 65 -- 35 31 16 15 18 16 * 14 15 15 17 ** 187 178 Ohio 143 128 38 35 82 76 34 30 18 18 23 21 * 17 15 16 16 219 214 Oklahoma 139 189 ** 38 32 * 80 71 * 40 35 * 17 16 24 23 24 24 16 15 ** 211 206 Oregon 40 41 17 17 48 46 15 14 14 14 17 17 10 8 14 15 ** 162 155 Pennsylvania 187 -- 31 28 74 70 31 27 18 17 22 21 17 16 17 17 187 181 Rhode Island 139 149 27 -- 66 62 28 25 18 17 24 21 * 12 10 15 15 188 196 South Carolina 138 133 27 25 65 62 33 30 16 16 21 20 19 20 16 16 176 169 South Dakota 72 76 22 22 -- -- 31 27 14 13 16 15 16 15 17 15 ** 168 149 * Tennessee 98 73 * 37 34 84 77 * 37 31 * 18 17 23 21 * 24 22 17 17 200 189 * Texas 104 114 31 29 76 70 34 28 * 17 16 23 22 24 23 15 15 186 180 Utah 80 93 17 16 42 39 17 16 13 13 14 14 11 11 14 14 147 142 Vermont 33 28 -- 20 65 61 31 27 16 15 16 16 13 15 16 15 ** 187 178 Virginia 107 100 27 25 71 63 * 40 36 18 17 22 21 20 20 17 17 193 187 Washington 77 84 18 17 49 48 23 21 15 15 19 17 * 13 13 15 15 157 156 West Virginia 110 98 50 43 * 98 87 * 46 40 * 20 19 23 23 20 19 18 17 ** 226 223 Wisconsin 78 86 22 21 60 57 26 23 16 15 17 17 13 12 16 16 182 176 Wyoming 92 123 * -- 23 -- -- 32 28 15 14 17 15 * 14 13 17 16 ** 169 160 Change 6 6 8 17 23 6 16 7 States Improved 3 6 8 17 23 6 10 7 States Worsened 3 0 0 0 0 0 6 0 Notes: * denotes a change of at least 0.5 standard deviations; ** denotes a change of 1.0 standard deviation or more. -- Data not available. (a) Not a scored indicator, included here for information only. 34 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit E3. Avoidable Hospital Use and Cost: Cost Indicators Total Medicare (Parts A & B) Health insurance premium for employer-sponsored reimbursements per enrolleea single-person plans Unadjusted Adjusted(b) Unadjusted Adjusted(b) Annual Growth Annual Growth 2012 2013 2012 2013 Rate(c) 2013 2014 2013 2014 Rate(c,d) United States $9,409 $9,289 $8,854 $8,801 -1.3% $5,571 $5,832 $5,633 $5,859 4.7% Alabama 8,686 8,469 9,344 9,250 -2.5% 5,204 5,526 6,450 6,849 6.2% Alaska 7,675 7,827 5,399 5,621 2.0% 7,369 7,099 5,701 5,492 -3.7% Arizona 8,588 8,459 7,998 7,943 -1.5% 5,343 5,356 5,014 5,026 0.2% Arkansas 8,158 8,017 8,619 8,548 -1.7% 4,536 4,846 5,328 5,692 6.8% California 10,244 10,167 8,310 8,285 -0.8% 5,581 5,841 4,197 4,392 4.7% Colorado 7,884 7,684 7,460 7,344 -2.5% 5,668 5,848 5,550 5,726 3.2% Connecticut 10,589 10,710 8,936 9,018 1.1% 6,002 6,223 4,820 4,997 3.7% Delaware 9,339 9,342 8,514 8,554 0.0% 5,934 6,145 5,562 5,759 3.6% District of Columbia 10,920 10,446 8,887 8,676 -4.3% 6,018 6,097 5,757 5,833 1.3% Florida 10,693 10,536 10,597 10,402 -1.5% 5,383 5,767 5,766 6,177 7.1% Georgia 8,664 8,511 8,743 8,693 -1.8% 5,374 5,570 5,917 6,133 3.6% Hawaii 6,432 6,410 5,408 5,421 -0.3% 5,103 5,316 4,355 4,537 4.2% Idaho 7,367 7,413 7,198 7,306 0.6% 5,019 4,978 5,557 5,511 -0.8% Illinois 9,797 9,650 9,219 9,167 -1.5% 5,824 6,126 5,781 6,081 5.2% Indiana 9,026 8,939 9,045 9,006 -1.0% 6,099 6,041 6,398 6,337 -1.0% Iowa 7,696 7,694 7,496 7,564 0.0% 5,207 5,557 5,641 6,020 6.7% Kansas 8,478 8,401 8,586 8,563 -0.9% 5,432 5,365 6,130 6,055 -1.2% Kentucky 8,971 8,913 9,167 9,161 -0.6% 5,257 5,914 6,080 6,840 12.5% Louisiana 10,334 10,076 10,868 10,697 -2.5% 5,300 5,700 6,345 6,824 7.5% Maine 8,015 8,049 7,606 7,653 0.4% 5,865 5,903 5,992 6,031 0.6% Maryland 10,655 10,563 8,472 8,616 -0.9% 5,730 6,059 5,741 6,071 5.7% Massachusetts 10,924 10,633 9,041 8,960 -2.7% 6,290 6,348 4,813 4,857 0.9% Michigan 10,131 9,989 9,565 9,521 -1.4% 5,319 5,610 5,483 5,783 5.5% Minnesota 7,936 8,017 7,225 7,320 1.0% 5,274 5,832 4,806 5,314 10.6% Mississippi 9,493 9,190 10,046 9,837 -3.2% 4,961 5,443 6,097 6,690 9.7% Missouri 8,610 8,486 8,698 8,627 -1.4% 5,442 5,517 6,062 6,145 1.4% Montana 6,939 6,987 6,585 6,687 0.7% 5,654 5,876 5,654 5,876 3.9% Nebraska 8,380 8,297 8,062 8,027 -1.0% 5,268 5,557 5,456 5,756 5.5% Nevada 9,222 9,133 8,328 8,295 -1.0% 5,168 5,426 4,461 4,684 5.0% New Hampshire 8,450 8,416 7,618 7,643 -0.4% 6,249 6,336 5,487 5,563 1.4% New Jersey 10,972 10,849 9,556 9,587 -1.1% 6,200 6,447 5,215 5,422 4.0% New Mexico 7,246 7,161 6,791 6,766 -1.2% 5,250 5,725 5,456 5,949 9.0% New York 10,960 10,873 8,977 8,975 -0.8% 6,156 6,307 5,157 5,283 2.5% North Carolina 8,296 8,209 8,158 8,160 -1.0% 5,218 5,593 5,813 6,230 7.2% North Dakota 7,651 7,683 7,529 7,585 0.4% 5,330 5,521 5,330 5,521 3.6% Ohio 9,537 9,440 9,492 9,406 -1.0% 5,679 5,930 6,244 6,520 4.4% Oklahoma 8,884 8,691 9,182 9,102 -2.2% 5,129 5,649 6,102 6,721 10.1% Oregon 7,021 7,066 6,300 6,380 0.6% 5,449 5,707 4,906 5,138 4.7% Pennsylvania 9,780 9,618 9,391 9,302 -1.7% 5,582 5,888 5,890 6,212 5.5% Rhode Island 9,610 9,637 8,557 8,594 0.3% 5,968 6,156 5,130 5,291 3.2% South Carolina 8,413 8,311 8,529 8,519 -1.2% 5,426 5,850 6,178 6,661 7.8% South Dakota 7,623 7,516 7,204 7,209 -1.4% 5,876 5,859 5,873 5,856 -0.3% Tennessee 8,736 8,437 9,197 9,044 -3.4% 5,146 5,310 6,078 6,271 3.2% Texas 10,152 9,990 10,135 10,067 -1.6% 5,386 5,740 5,807 6,188 6.6% Utah 7,997 7,804 8,011 7,889 -2.4% 5,309 5,538 5,832 6,084 4.3% Vermont 7,898 7,884 6,816 6,869 -0.2% 5,764 6,180 5,719 6,131 7.2% Virginia 8,160 8,169 8,000 8,050 0.1% 5,408 5,422 5,800 5,815 0.3% Washington 7,919 7,922 7,106 7,137 0.0% 5,690 5,910 5,031 5,226 3.9% West Virginia 8,520 8,434 8,637 8,601 -1.0% 5,940 6,149 7,334 7,592 3.5% Wisconsin 8,003 7,979 7,615 7,622 -0.3% 5,730 5,868 5,730 5,868 2.4% Wyoming 7,715 7,518 6,818 6,701 -2.6% 6,301 5,840 6,258 5,801 -7.3% Notes: (a) Medicare spending estimates exclude prescription drug costs and reflect only the age 65+ Medicare fee-for-service population. (b) Spending is standardized for state differences in input prices using CMS’ hospital wage index and extra CMS payments for graduate medical education and for treating low-income patients are removed from Medicare spending estimates. (c) Average annual growth rate calculated on the unadjusted amounts. (d) Average annual growth rate of + or - 3.5% or more in a state’s health insurance premiums represents a change of at least 0.5 standard deviations. 35 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit F1. Healthy Lives: Dimension and Indicator Ranking e lif of n) 0) ty th io 00 ) e hs ali es lat ee Overall performance, 2015 0, irt 0 qu ob et io e 10 pu 00 lat ar eb n) or ed po or 0, er pu h c liv m 10 lat (p ht 0 po lt Top quartile 00 or 00 e ig re 0 ea st er lat s n) 0, ix h- lo ,0 00 h n) (p pu ath rw io 10 ts r1 alt 0, to Second quartile fe e (p orec atio ths ve po e es os l li pe he 10 ble er 0 rd eo e l a ob el (p t ia ok y( pu de 00 ce or er na Third quartile ar av re hs m en lit 0, an po sp e po cer ho oh oa os th am ta at ot 10 l c th ale n Bottom quartile nw or de fp wh wh wh er ta m ca wi ea ty m so de (d rtali re st ts ts ts ts nt ild ici ea ar ul ul ul ul fa l o Ad Ad Ad Ad Su Co Ch Ye Br In M fe 1 Minnesota ! ! " ! " ! ! " ! ! ! 2 Colorado ! ! ! ! # ! " ! ! ! ! 2 Connecticut ! ! ! ! ! ! " ! ! " ! 4 Massachusetts ! ! ! ! ! ! " ! ! $ " 4 Utah ! " " ! # " ! ! ! ! ! 6 Hawaii " ! ! " ! $ ! ! ! ! ! 7 California " ! " ! ! ! $ ! ! " ! 7 New Hampshire ! ! " ! " " ! " ! ! " 9 Vermont ! ! ! " $ ! " " ! ! " 10 Rhode Island " " ! ! " $ " " ! " ! 10 Washington ! ! " ! $ ! $ ! " ! ! 12 New Jersey " ! # $ ! ! ! ! ! ! " 13 New York $ ! $ " ! ! " ! ! $ " 14 Nebraska ! ! $ $ ! " ! " $ " ! 14 Oregon ! " " " $ ! $ " " ! ! 16 Iowa " " ! $ $ ! ! $ $ " " 17 Idaho ! " # " # " ! ! " " ! 18 Wisconsin " " " " $ $ " " $ " " 18 Wyoming " $ " ! # ! ! $ $ ! " 20 Maryland $ " $ " ! $ ! ! " $ " 20 Virginia $ " $ " " $ " $ " " " 22 District of Columbia # $ # " ! $ ! ! ! # ! 22 Florida $ " " " " " # " ! " $ 22 Illinois $ " # $ ! " " " " $ ! 22 Montana " $ " ! # " " $ ! " $ 22 Texas $ " " $ ! " $ ! $ # ! 27 Kansas " $ ! $ $ $ " " $ " " 27 North Dakota " $ ! $ # " ! $ # # ! 29 Arizona " $ $ " # " $ ! " # " 29 Maine ! " ! ! # # $ $ " " $ 29 South Dakota " " " # # $ ! $ $ ! " 32 Alaska " $ ! # # " " $ " " " 33 Delaware $ $ $ " " $ " $ $ $ $ 34 New Mexico $ # ! $ # " # $ " $ " 34 Pennsylvania $ $ $ $ " $ $ $ $ ! " 36 Nevada $ $ # # # " $ " " $ ! 36 North Carolina $ $ " " " # $ $ $ $ $ 38 Michigan $ $ $ $ " # $ # " $ " 39 Georgia # $ # $ ! # $ " $ # $ 40 Missouri # # # $ $ $ " # $ " $ 41 Ohio # # # # " # $ # $ $ $ 42 Indiana $ # $ $ $ # $ # # $ # 43 South Carolina # # $ $ " # # # # # # 44 Kentucky # # $ # $ $ # # # # # 44 Tennessee # # # # $ # # # # $ # 46 Alabama # # $ # $ # # # # # # 46 Oklahoma # # # # $ $ # # # $ # 48 Louisiana # # # # " # # # # # # 49 Arkansas # # $ # # # # # # $ # 50 West Virginia # # $ # $ # # # # $ # 51 Mississippi # # # # " # # # # # # 36 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit F2. Healthy Lives: Dimension Ranking and Indicator Rates Mortality amenable Breast cancer deaths Colorectal cancer Suicide deaths Infant mortality, to health care, deaths Years of potential life per 100,000 female deaths per 100,000 per 100,000 deaths per 1,000 per 100,000 population lost before age 75 population population population live births 2010-11 2012-13 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 United States 85 84 6,412 6,420 21.4 20.8 14.9 14.6 12.6 12.6 6.0 6.0 Alabama 112 111 9,324 9,368 22.9 21.4 * 16.7 17.7 * 14.7 14.4 8.9 8.6 Alaska 72 72 7,194 7,308 17.6 19.3 * 15.6 16.4 23.1 23.1 5.1 5.8 * Arizona 74 72 6,609 6,645 19.1 20.6 * 13.1 13.3 17.3 17.5 5.8 5.3 Arkansas 116 119 8,928 8,867 23.3 21.4 * 17.7 17.7 16.3 17.3 7.1 7.9 * California 73 72 5,108 5,123 21.1 20.1 13.6 13.2 10.0 10.2 4.5 4.8 Colorado 62 59 5,538 5,555 20.3 18.1 * 12.6 12.3 19.7 18.6 4.6 5.1 Connecticut 64 61 5,146 5,109 19.2 18.7 12.1 11.9 9.9 8.7 5.3 4.8 Delaware 88 85 7,204 6,892 22.7 21.3 * 13.4 13.8 13.2 12.5 7.6 6.4 ** District of Columbia 130 124 7,831 7,285 31.1 29.8 * 12.8 14.3 * 5.7 5.8 7.9 6.7 ** Florida 81 80 6,556 6,502 20.6 19.6 13.8 13.7 14.3 13.8 6.1 6.1 Georgia 103 100 6,966 7,229 21.6 22.5 15.1 14.9 11.7 12.0 6.2 7.0 * Hawaii 70 75 5,445 5,611 16.3 15.5 13.6 14.2 13.1 11.8 4.9 6.4 ** Idaho 66 67 5,809 6,201 15.8 22.1 ** 14.2 13.4 19.0 19.2 5.4 5.6 Illinois 90 87 6,161 5,994 23.0 22.2 16.0 15.9 9.8 9.9 6.5 6.0 Indiana 93 91 7,342 7,487 21.8 21.8 16.4 15.4 * 14.3 14.3 6.7 7.2 Iowa 73 72 5,747 5,679 20.3 18.7 * 15.9 15.6 12.7 14.4 5.3 4.3 * Kansas 78 78 6,643 6,555 23.0 18.5 ** 14.7 15.4 17.5 14.7 * 6.3 6.5 Kentucky 107 106 8,869 8,374 23.4 21.1 * 17.1 17.1 16.2 15.5 7.2 6.4 * Louisiana 121 123 8,952 9,232 24.4 23.9 17.7 18.4 12.4 12.4 8.1 8.7 * Maine 65 62 6,128 6,252 17.3 18.8 * 14.2 12.5 * 14.5 17.4 * 7.0 7.1 Maryland 92 89 6,244 6,248 23.7 21.5 * 15.0 14.3 9.5 9.2 6.4 6.6 Massachusetts 64 60 4,892 5,009 19.5 18.4 * 13.4 13.1 8.7 8.2 4.2 4.2 Michigan 92 91 6,977 7,023 22.3 21.2 * 14.5 14.8 12.5 12.9 6.9 7.1 Minnesota 57 56 4,910 4,963 18.1 19.6 * 13.2 12.8 12.0 12.1 5.0 5.1 Mississippi 133 137 9,610 9,945 25.3 23.3 * 19.4 18.8 14.0 13.0 8.9 9.6 * Missouri 95 95 7,487 7,480 22.5 22.0 16.6 15.7 * 14.9 15.6 6.6 6.5 Montana 69 70 6,963 7,197 20.7 19.9 14.3 12.4 ** 22.6 23.7 5.9 5.6 Nebraska 66 65 5,701 5,607 21.2 21.0 16.0 15.2 12.5 11.6 4.7 5.2 Nevada 94 92 6,658 6,846 22.2 22.5 17.7 16.8 * 18.2 18.6 4.9 5.3 New Hampshire 60 58 5,097 5,329 19.0 19.8 13.7 12.8 * 14.1 12.8 4.2 5.6 ** New Jersey 79 75 5,325 5,345 22.7 23.2 15.9 14.9 * 7.4 8.0 4.4 4.5 New Mexico 78 79 7,998 7,686 18.0 17.3 13.9 14.5 21.3 20.3 6.8 5.3 ** New York 82 79 5,237 5,216 20.8 20.6 14.4 14.0 8.3 8.1 5.0 4.9 North Carolina 94 93 7,029 6,976 21.5 20.4 * 14.5 13.3 * 12.7 12.6 7.4 7.0 North Dakota 70 70 6,473 6,655 16.9 17.9 13.2 15.9 ** 15.2 17.3 * 6.3 6.0 Ohio 96 94 7,282 7,365 22.8 22.9 16.4 16.3 13.0 12.9 7.5 7.3 Oklahoma 114 118 8,915 9,041 23.4 22.9 18.1 17.5 17.6 17.2 7.5 6.7 * Oregon 65 62 5,799 5,736 20.3 19.9 13.8 14.4 17.8 16.8 5.4 4.9 Pennsylvania 86 82 6,726 6,648 22.6 21.8 16.0 15.9 12.4 13.4 7.1 6.7 Rhode Island 73 68 5,549 5,819 18.1 19.4 * 14.4 13.2 * 9.5 12.2 * 6.5 6.5 South Carolina 103 99 7,962 7,908 22.3 21.3 15.4 15.0 13.7 14.0 7.5 6.9 * South Dakota 75 75 6,873 6,514 19.5 19.9 16.4 16.7 16.8 18.0 8.3 6.5 ** Tennessee 110 110 8,464 8,357 22.9 22.4 16.9 16.6 14.6 15.3 7.2 6.8 Texas 93 93 6,457 6,492 21.1 20.2 14.8 14.7 11.9 11.7 5.8 5.8 Utah 62 61 5,719 5,722 20.4 20.3 10.7 10.9 21.0 21.4 4.8 5.2 Vermont 58 57 5,102 5,596 19.4 18.5 13.5 14.3 13.1 16.8 * 4.3 4.4 Virginia 83 81 5,965 5,882 21.3 21.1 14.5 13.8 12.6 12.5 6.5 6.2 Washington 64 62 5,399 5,313 17.9 20.5 ** 13.2 12.8 14.5 14.1 5.3 4.5 * West Virginia 105 103 9,474 9,413 22.6 21.6 17.5 19.8 ** 17.1 16.4 7.2 7.6 Wisconsin 72 69 5,696 5,863 20.4 20.4 13.8 14.1 12.3 14.4 * 5.7 6.3 * Wyoming 76 68 7,046 6,761 15.7 20.5 ** 15.8 12.6 ** 29.6 21.5 ** 5.6 4.8 * Change 0 0 21 14 7 18 States Improved 0 0 13 10 2 10 States Worsened 0 0 8 4 5 8 Notes: * denotes a change of at least 0.5 standard deviations; ** denotes a change of 1.0 standard deviation or more. 37 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit F2. Healthy Lives: Dimension Ranking and Indicator Rates (continued) Adults with poor Children who Adults ages 18–64 health-related are overweight who have lost six quality of life Adults who smoke Adults who are obese or obese or more teeth 2013 2014 2013 2014 2013 2014 2011/12 2012 2014 United States 26% 27% 18% 17% 29% 29% 31% 10% 10% Alabama 31 33 * 21 20 33 35 * 35 17 17 Alaska 24 24 22 19 * 28 30 * 30 9 9 Arizona 24 28 ** 16 15 28 30 * 37 10 9 Arkansas 33 32 25 24 37 38 34 17 17 California 29 28 11 12 25 25 30 7 7 Colorado 23 24 17 14 * 22 21 23 7 7 Connecticut 21 25 ** 15 14 25 26 30 8 8 Delaware 25 24 19 19 31 31 32 10 11 District of Columbia 21 19 * 18 15 * 23 21 * 35 7 7 Florida 28 29 16 17 27 27 28 11 11 Georgia 27 26 18 16 * 31 31 35 13 12 Hawaii 20 22 * 13 13 23 24 27 6 7 Idaho 23 23 17 15 * 30 30 28 9 8 Illinois 22 24 * 18 16 * 30 29 34 9 8 Indiana 26 28 * 21 22 32 34 * 31 13 14 Iowa 22 22 19 18 32 31 28 9 10 Kansas 23 24 20 17 * 31 32 30 10 9 Kentucky 32 34 * 25 25 34 33 36 16 18 * Louisiana 30 29 23 23 33 36 * 40 17 14 * Maine 25 27 * 20 19 29 29 30 14 13 Maryland 22 23 16 14 * 29 30 32 9 9 Massachusetts 22 25 * 16 14 * 24 23 31 9 10 Michigan 28 26 * 21 21 32 30 * 33 11 10 Minnesota 20 20 17 16 26 27 27 7 7 Mississippi 31 30 24 22 * 37 37 40 18 19 Missouri 28 25 * 22 20 * 31 31 28 12 13 Montana 25 25 19 19 25 26 29 11 11 Nebraska 22 21 18 17 30 31 29 8 8 Nevada 25 26 19 16 * 27 28 33 11 8* New Hampshire 22 22 16 17 27 27 26 10 10 New Jersey 22 23 15 14 27 27 25 9 10 New Mexico 29 30 19 18 28 30 * 33 10 10 New York 25 25 16 14 * 25 27 * 32 10 9 North Carolina 27 27 20 18 * 30 31 31 13 13 North Dakota 20 20 21 19 * 31 33 * 36 9 7* Ohio 26 27 22 21 31 32 31 13 13 Oklahoma 30 30 23 21 * 34 34 34 14 14 Oregon 26 28 * 17 16 27 28 26 10 8* Pennsylvania 24 27 * 20 19 30 31 26 11 10 Rhode Island 25 24 17 16 27 27 28 9 7* South Carolina 28 29 21 21 33 33 39 15 15 South Dakota 21 21 19 18 30 31 27 9 10 Tennessee 31 32 23 23 35 33 * 34 18 16 * Texas 24 26 * 15 14 32 32 37 8 7 Utah 20 21 10 9 24 25 22 6 6 Vermont 22 24 * 16 16 25 25 25 11 10 Virginia 23 24 18 19 27 29 * 30 11 10 Washington 28 27 16 15 27 28 26 8 8 West Virginia 34 34 27 26 37 37 34 23 22 Wisconsin 24 24 18 17 29 31 * 29 11 10 Wyoming 23 23 20 19 29 31 * 27 11 10 Change 16 16 14 7 States Improved 3 16 3 6 States Worsened 13 0 11 1 Notes: * denotes a change of at least 0.5 standard deviations; ** denotes a change of 1.0 standard deviation or more. 38 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit F3. Mortality Amenable to Health Care by Race, Deaths per 100,000 population, 2010–11 and 2012–13 Total White Black Change Change Change 2010-11 2012-13 in Rate 2015 Rank 2010-11 2012-13 in Rate 2015 Rank 2010-11 2012-13 in Rate 2015 Rank United States 85 84 -1 -- 78 77 -1 -- 161 155 -6 -- Alabama 112 111 -1 46 96 97 1 43 175 166 -9 35 Alaska 72 72 0 18 63 64 1 14 83 98 15 2 Arizona 74 72 -2 18 70 69 -1 21 131 127 -4 12 Arkansas 116 119 3 48 107 111 4 50 196 197 1 43 California 73 72 -1 18 72 72 0 26 154 148 -6 22 Colorado 62 59 -3 4 59 56 -3 3 122 106 -16 7 Connecticut 64 61 -3 6 58 57 -1 4 113 109 -4 10 Delaware 88 85 -3 31 80 75 -5 29 138 133 -5 13 District of Columbia 130 124 -6 50 49 41 -8 1 190 186 -4 39 Florida 81 80 -1 28 78 77 -1 34 142 139 -3 15 Georgia 103 100 -3 42 87 86 -1 38 160 151 -9 23 Hawaii 70 75 5 22 59 59 0 6 70 106 36 7 Idaho 66 67 1 12 66 68 2 20 -- -- -- -- Illinois 90 87 -3 32 79 76 -3 32 183 178 -5 37 Indiana 93 91 -2 34 89 87 -2 39 160 159 -1 29 Iowa 73 72 -1 18 72 70 -2 22 146 151 5 23 Kansas 78 78 0 25 75 75 0 29 141 147 6 21 Kentucky 107 106 -1 44 104 104 0 48 164 155 -9 27 Louisiana 121 123 2 49 100 101 1 45 185 189 4 40 Maine 65 62 -3 8 66 63 -3 12 -- 99 -- 3 Maryland 92 89 -3 33 76 76 0 32 145 135 -10 14 Massachusetts 64 60 -4 5 62 60 -2 7 104 90 -14 1 Michigan 92 91 -1 34 79 77 -2 34 189 190 1 42 Minnesota 57 56 -1 1 55 53 -2 2 101 100 -1 5 Mississippi 133 137 4 51 104 109 5 49 198 198 0 44 Missouri 95 95 0 40 88 89 1 42 175 166 -9 35 Montana 69 70 1 16 66 66 0 16 -- -- -- -- Nebraska 66 65 -1 11 64 62 -2 10 139 141 2 18 Nevada 94 92 -2 36 98 97 -1 43 147 145 -2 20 New Hampshire 60 58 -2 3 61 60 -1 7 88 -- -- -- New Jersey 79 75 -4 22 73 71 -2 24 155 144 -11 19 New Mexico 78 79 1 26 73 72 -1 26 145 106 -39 7 New York 82 79 -3 26 73 71 -2 24 144 140 -4 16 North Carolina 94 93 -1 37 81 81 0 36 156 151 -5 23 North Dakota 70 70 0 16 65 66 1 16 -- -- -- -- Ohio 96 94 -2 39 88 87 -1 39 170 164 -6 33 Oklahoma 114 118 4 47 108 113 5 51 193 189 -4 40 Oregon 65 62 -3 8 66 63 -3 12 106 112 6 11 Pennsylvania 86 82 -4 30 78 75 -3 29 171 162 -9 32 Rhode Island 73 68 -5 13 73 70 -3 22 113 102 -11 6 South Carolina 103 99 -4 41 85 83 -2 37 163 156 -7 28 South Dakota 75 75 0 22 67 66 -1 16 -- -- -- -- Tennessee 110 110 0 45 101 101 0 45 183 179 -4 38 Texas 93 93 0 37 86 88 2 41 171 164 -7 33 Utah 62 61 -1 6 61 60 -1 7 115 161 46 31 Vermont 58 57 -1 2 58 57 -1 4 -- -- -- -- Virginia 83 81 -2 29 72 72 0 26 147 140 -7 16 Washington 64 62 -2 8 63 62 -1 10 111 99 -12 3 West Virginia 105 103 -2 43 104 103 -1 47 159 154 -5 26 Wisconsin 72 69 -3 15 67 64 -3 14 175 160 -15 30 Wyoming 76 68 -8 13 75 67 -8 19 -- -- -- -- Notes: * denotes a change of at least 0.5 standard deviations; ** denotes a change of 1.0 standard deviation or more. 39 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit G1. Equity: Dimension and SubDimension Ranking Overall performance, 2015 Top quartile Second quartile Third quartile Bottom quartile Income Race/Ethnicity Subdimension Subdimension 1 Hawaii 2 2 2 Massachusetts 2 2 3 Connecticut 2 2 3 Vermont 2 2 5 New Hampshire 2 2 5 New York 2 2 7 Rhode Island 2 2 8 Washington 2 2 9 District of Columbia 2 2 9 Minnesota 2 3 11 Colorado 3 2 11 Oregon 3 2 13 Maryland 3 2 14 Delaware 2 3 15 Iowa 2 3 15 Maine 2 3 17 New Jersey 3 3 17 South Dakota 2 4 19 Pennsylvania 3 4 20 Nebraska 3 3 20 New Mexico 3 3 22 California 3 3 22 Idaho 3 3 24 Arizona 4 3 24 Illinois 3 4 24 Utah 3 4 24 Virginia 4 3 28 Missouri 5 3 29 Alaska 5 3 29 Wisconsin 3 5 31 Florida 5 3 31 Michigan 3 4 31 Texas 4 4 31 West Virginia 4 4 35 Wyoming 4 4 36 Kansas 4 4 36 Montana 4 4 36 North Dakota 4 4 39 Nevada 4 4 39 Tennessee 4 4 41 Ohio 5 4 42 Alabama 5 4 43 North Carolina 4 5 44 Louisiana 5 4 45 Georgia 5 5 45 Kentucky 5 5 47 Indiana 5 5 48 South Carolina 5 5 49 Mississippi 5 5 49 Oklahoma 5 5 51 Arkansas 5 5 40 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix Exhibit G2. Equity : Summary of Indicator Change Over Time Total Race/Ethnicity Income Number of Number of Percent of Number of Number of Percent of Number of Number of Percent of indicators indicators indicators indicators indicators indicators indicators indicators indicators improved with data improved improved with data improved improved with data improved Alabama 10 27 37% 5 12 42% 5 15 33% Alaska 9 26 35% 6 11 55% 3 15 20% Arizona 18 28 64% 8 13 62% 10 15 67% Arkansas 10 27 37% 2 12 17% 8 15 53% California 14 28 50% 8 13 62% 6 15 40% Colorado 12 28 43% 6 13 46% 6 15 40% Connecticut 13 28 46% 2 13 15% 11 15 73% Delaware 11 28 39% 4 13 31% 7 15 47% District of Columbia 15 27 56% 6 12 50% 9 15 60% Florida 14 28 50% 8 13 62% 6 15 40% Georgia 10 28 36% 5 13 38% 5 15 33% Hawaii 9 25 36% 1 10 10% 8 15 53% Idaho 9 27 33% 3 12 25% 6 15 40% Illinois 18 28 64% 8 13 62% 10 15 67% Indiana 10 27 37% 6 12 50% 4 15 27% Iowa 7 27 26% 4 12 33% 3 15 20% Kansas 8 28 29% 1 13 8% 7 15 47% Kentucky 13 27 48% 5 12 42% 8 15 53% Louisiana 13 27 48% 6 12 50% 7 15 47% Maine 5 24 21% 1 9 11% 4 15 27% Maryland 13 28 46% 6 13 46% 7 15 47% Massachusetts 14 28 50% 6 13 46% 8 15 53% Michigan 8 27 30% 1 12 8% 7 15 47% Minnesota 11 27 41% 4 12 33% 7 15 47% Mississippi 7 28 25% 4 13 31% 3 15 20% Missouri 11 27 41% 7 12 58% 4 15 27% Montana 12 28 43% 6 13 46% 6 15 40% Nebraska 10 28 36% 5 13 38% 5 15 33% Nevada 14 27 52% 5 12 42% 9 15 60% New Hampshire 8 24 33% 2 9 22% 6 15 40% New Jersey 14 28 50% 6 13 46% 8 15 53% New Mexico 9 28 32% 2 13 15% 7 15 47% New York 17 28 61% 8 13 62% 9 15 60% North Carolina 18 27 67% 8 12 67% 10 15 67% North Dakota 8 27 30% 5 12 42% 3 15 20% Ohio 8 28 29% 5 13 38% 3 15 20% Oklahoma 16 28 57% 8 13 62% 8 15 53% Oregon 15 28 54% 7 13 54% 8 15 53% Pennsylvania 7 28 25% 2 13 15% 5 15 33% Rhode Island 19 28 68% 7 13 54% 12 15 80% South Carolina 6 28 21% 3 13 23% 3 15 20% South Dakota 11 28 39% 6 13 46% 5 15 33% Tennessee 13 26 50% 5 11 45% 8 15 53% Texas 12 28 43% 4 13 31% 8 15 53% Utah 7 26 27% 2 11 18% 5 15 33% Vermont 9 24 38% 3 9 33% 6 15 40% Virginia 12 28 43% 7 13 54% 5 15 33% Washington 11 28 39% 5 13 38% 6 15 40% West Virginia 13 27 48% 4 12 33% 9 15 60% Wisconsin 6 27 22% 2 12 17% 4 15 27% Wyoming 10 26 38% 7 11 64% 3 15 20% 41 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix exhibit h1. Scorecard Indicator Descriptions and Source Notes 1. Percent of adults ages 19-64 uninsured: Authors’ analysis of 2013 and developmental, or behavioral problem that required treatment or 2014 1-year American Community Survey (ACS) Public Use Micro Sample counseling and who received treatment from a mental health professional (PUMS)(U.S. Census Bureau, ACS PUMS, 2013, 2014). (as defined) during the past 12 months. For more information, see www. childhealthdata.org. Authors’ analysis of 2011/12 National Survey of 2. Percent of children ages 0-18 uninsured: Authors’ analysis of 2013 Children’s Health (CAHMI, NSCH 2011/12). and 2014 1-year American Community Survey (ACS) Public Use Micro Sample (PUMS)(U.S. Census Bureau, ACS PUMS, 2013, 2014). 12. Percent of children ages 19-35 months who received all recommended doses of seven key vaccines: Percent of children ages 3. Percent of adults who went without care because of cost in the 19-35 months who received at least 4 doses of diphtheria, tetanus, and past year: Authors’ analysis of 2013 and 2014 Behavioral Risk Factor accellular pertussis (DTaP/DT/DTP) vaccine; at least 3 doses of poliovirus Surveillance System (NCCDPHP, BRFSS 2013, 2014). vaccine; at least 1 dose of measles-containing vaccine (including mumps- 4. Percent of individuals under age 65 with high out-of-pocket medical rubella(MMR) vaccine); full series of Haemophilus influenza type b (Hib) spending relative to their annual income: Out-of-pocket medical expenses vaccine (3 or 4 doses depending on product type); at least 3 doses of equaled 10 percent or more of income, or five percent or more of income hepatitis B vaccine (HepB); at least 1 dose of varicella vaccine, and at least if low-income (under 200% of Federal Poverty Level), not including health 4 doses of pneumococcal conjugate vaccine (PCV). Data from the 2012 insurance premiums. C. Solis-Roman, Robert F. Wagner School of Public and 2013 NNational Immunization Survey (NIS) Public Use Files and 2014 Service, New York University, analysis of 2014 and 2015 Current Population as published in the August 28, 2015 Morbidity and Mortality Weekly Report, Survey, Annual Social and Economic Supplement (U.S. Census Bureau, CPS Vol.64 No.33 (NCHS, NIS 2013, 2014). (2012 and 2013 data used for ASES 2014, 2015). stratification by income and race/ethnicity for equity analysis.) 5. At-risk adults without a routine doctor visit in past two years: 13. Percent of Medicare beneficiaries received at least one drug that Percent of adults age 50 or older, or in fair or poor health, or ever told they should be avoided in the elderly: Percent of Medicare beneficiaries age have diabetes or pre-diabetes, acute myocardial infarction, heart disease, 65 and older received at least one drug from a list of 13 classes of high-risk stroke, or asthma who did not visit a doctor for a routine checkup in the prescriptions that should be avoided by the elderly. Y. Zhang and S.H. Baik, past two years. Authors’ analysis of 2013 and 2014 Behavioral Risk Factor University of Pittsburgh, analysis of 2011 and 2012 5% sample of Medicare Surveillance System (NCCDPHP, BRFSS 2013, 2014). beneficiaries enrolled in stand-alone Medicare Part D plans. 6. Percent of adults without a dental visit in the past year: Percent 14. Percent of Medicare beneficiaries with dementia, hip/pelvic fracture, of adults who did not visit a dentist, or dental clinic within the past year. or chronic renal failure received prescription in an ambulatory care Authors’ analysis of 2012 and 2014 Behavioral Risk Factor Surveillance setting that is contraindicated for that condition: Y. Zhang and S.H. Baik, System (NCCDPHP, BRFSS 2012, 2014). University of Pittsburgh, analysis of 2011 and 2012 5% sample of Medicare beneficiaries enrolled in stand-alone Medicare Part D plans. 7. Percent of adults with a usual source of care: Percent of adults ages 18 and older who have one (or more) person they think of as their personal 15. Medicare fee-for-service patients whose health provider always healthcare provider. Authors’ analysis of 2013 and 2014 Behavioral Risk listens, explains, shows respect, and spends enough time with them: Factor Surveillance System (NCCDPHP, BRFSS 2013, 2014). Percent of Medicare fee-for-service patients who had a doctor’s office or clinic visit in the last 12 months whose health providers always listened 8. Percent of adults age 50 and older received recommended screening carefully, explained things clearly, respected what they had to say, and and preventive care: Percent of adults age 50 and older who have spent enough time with them. Data from National Consumer Assessment received: sigmoidoscopy or colonoscopy in the last ten years or a fecal of Healthcare Providers and Systems (CAHPS) Benchmarking Database occult blood test in the last two years; a mammogram in the last two years (AHRQ, CAHPS n.d.), reported in National Healthcare Quality Report (AHRQ (women only); a pap smear in the last three years (women only); and a flu 2013). shot in the past year and a pneumonia vaccine ever (age 65 and older only). Authors’ analysis of 2012 and 2014 Behavioral Risk Factor Surveillance 16. Risk-adjusted 30-day mortality among Medicare patients System (NCCDPHP, BRFSS 2012, 2014). hospitalized for heart attack, heart failure or pneumonia: Risk- standardized, all-cause 30-day mortality rates for Medicare patients age 9. Percent of children with a medical home: Percent of children who 65 and older hospitalized with a principal diagnosis of heart attack, heart have a personal doctor or nurse, have a usual source for sick and well care, failure or pneumonia between July 2009 and June 2012 and July 2010 and receive family-centered care, have no problems getting needed referrals, June 2013. All-cause mortality is defined as death from any cause within and receive effective care coordination when needed. For more information, 30 days after the index admission, regardless of whether the patient dies see www.childhealthdata.org. Authors’ analysis of 2011/12 National Survey while still in the hospital or after discharge. Authors’ analysis of Medicare of Children’s Health (CAHMI, NSCH 2011/12). enrollment and claims data retrieved April 2015 from CMS Hospital 10. Percent of children with a medical and dental preventive care visit in Compare (DHHS n.d.). the past year: Percent of children 0-17 with a preventive medical visit and, 17. Percent of hospitalized patients who were given information about if ages 1-17, a preventive dental visit in the past year. For more information, what to do during their recovery at home: Authors’ analysis of Hospital see www.childhealthdata.org. Authors’ analysis of 2011/12 National Survey Consumer Assessment of Healthcare Providers and Systems Survey data of Children’s Health (CAHMI, NSCH 2011/12). (HCAHPS n.d.) retrieved April 2015 from CMS Hospital Compare (DHHS n.d.). 11. Percent of children with emotional, behavioral, or developmental 18. Percent of patients reported hospital staff always managed pain problems who received needed mental health care in the past well, responded when needed help to get to bathroom or pressed call year: Percent of children ages 2-17 who had any kind of emotional, 42 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix exhibit h1. Scorecard Indicator Descriptions and Source Notes (continued) button, and explained medicines and side effects: Authors’ analysis of February 2015 CMS Geographic Variation Public Use File (CMS, Office of Hospital Consumer Assessment of Healthcare Providers and Systems Information Products and Analytics (OPIDA) 2015). Survey data (HCAHPS n.d.) retrieved April 2015 from CMS Hospital Compare (DHHS n.d.). 25. Medicare 30-day hospital readmissions, rate per 1,000 beneficiaries: All hospital admissions among Medicare beneficiaries age 19. Home health patients who get better at walking or moving around: 65 and older that were readmitted within 30 days of an acute hospital Percent of all home health episodes in which a person improved at stay for any cause. A correction was made to account for likely transfers walking or moving around compared to a prior assessment. Episodes for between hospitals. Authors’ analysis of 2007-2013 Chronic Conditions which the patient, at start or resumption of care, was able to ambulate Warehouse (CCW) data, retrieved from the February 2015 CMS Geographic independently are excluded. Authors’ analysis of 2013 and 2014 Outcome Variation Public Use File (CMS, Office of Information Products and and Assessment Information Set (CMS, OASIS n.d.) as reported in CMS Analytics (OPIDA) 2015). Home Health Compare. Data retrieved April 2014 and April 2015 from CMS Home Health Compare (DHHS n.d.). 26. Percent of short-stay nursing home residents readmitted within 30 days of hospital discharge to the nursing home: Percent of newly 20. Home health patients whose wounds improved or healed after admitted nursing home residents (never been in a facility before) who are an operation: Percent of all home health episodes in which a person’s re-hospitalized within 30 days of being discharged to nursing home. V.Mor, surgical wound is more fully healed compared to a prior assessment. Brown University, analysis of 2010 and 2012 Medicare enrollment data and Episodes for which the patient, at start or resumption of care, did not have Medicare Provider and Analysis Review (CMS, MEDPAR 2010, 2012). any surgical wounds or had only a surgical wound that was unobservable are excluded. Authors’ analysis of 2013 and 2014 Outcome and 27. Percent of long-stay nursing home residents hospitalized within Assessment Information Set (CMS, OASIS n.d.) as reported in CMS Home a six-month period: Percent of long-stay residents (residing in a nursing Health Compare. Data retrieved April 2014 and April 2015 from CMS Home home for at least 90 consecutive days) who were ever hospitalized within Health Compare (DHHS n.d.). six months of baseline assessment. V.Mor, Brown University, analysis of 2010 and 2012 Medicare enrollment data, Medicare Provider and Analysis 21. High-risk nursing home residents with pressure sores: Percent of Review File (CMS, MEDPAR 2010, 2012). long-stay nursing home residents impaired in bed mobility or transfer, comatose, or malnourished who have pressure sores (Stages 1–4) on 28. Home health patients also enrolled in Medicare with a hospital target assessment. Authors’ analysis of 2013 and 2014 Minimum Data Set admission: Percent of acute care hospitalization for home health episodes (CMS, MDS n.d.) as reported in CMS Nursing Home Compare, 2013 and that occurred in 2013 and 2014. Authors’ analysis data from CMS Medicare 2014 single quarter quality measure summary files. Data retrieved October claims data retrieved April 2014 and April 2015 from CMS Home Health 2015 from CMS Nursing Home Compare. Compare (DHHS n.d.). 22. Long-stay nursing home residents with an antipsychotic 29. Potentially avoidable emergency department visits among Medicare medication: The percent of long-stay nursing home residents that received beneficiaries, per 1,000 beneficiaries: Potentially avoidable emergency an antipsychotic medication, excluding residents with Schizophrenia, department visits were those that, based on diagnoses recorded during Tourette’s syndrome, and Huntington’s disease. Authors’ analysis of 2013 the visit and the health care service the patient received, were considered and 2014 Minimum Data Set (CMS, MDS n.d.) as reported in CMS Nursing to be either non-emergent (care was not needed within 12 hours), or Home Compare, 2013 and 2014 single quarter quality measure summary emergent (care needed within 12 hours) but that could have been treated files. Data retrieved October 2015 from CMS Nursing Home Compare. safely and effectively in a primary care setting. This definition excludes any emergency department visit that resulted in an admission, as well as 23. Hospital admissions for pediatric asthma, per 100,000 children emergency department visits where the level of care provided in the ED was (ages 2-17): Excludes patients with cystic fibrosis or anomalies of the clinically indicated. J. Zheng, Harvard University, analysis of 2012 and 2013 respiratory system, and transfers from other institutions. Authors’ analysis Medicare Enrollment and Claims Data 20% sample, Chronic Conditions of 2011 and 2012 Healthcare Cost and Utilization Project State Inpatient Warehouse (CMS, CCW 2012, 2013), using the New York University Center Databases; not all states participate in HCUP. Estimates for total U.S. are for Health and Public Service Research emergency department algorithm from the Nationwide Inpatient Sample (AHRQ, HCUPT-SID 2011, 2012). developed by John Billings. Reported in the National Healthcare Quality Report (AHRQ 2011, 2012). 30. Total single premium per enrolled employee at private-sector 24. Hospital admissions for ambulatory care-sensitive conditions, per establishments that offer health insurance: Data from Medical 1,000 beneficiaries: Expenditure Panel Survey–Insurance Component (AHRQ, MEPS-IC 2008, 2013, 2014). Medicare beneficiaries ages 65-74: 31. Total Medicare (Parts A&B) reimbursements per enrollee: Total Medicare beneficiaries ages 75 and older: Medicare fee-for-service reimbursements include payments for both Part Hospital admissions of fee-for-service Medicare beneficiaries age 65-74 A and Part B but exclude Part D (prescription drug costs) and extra CMS and 75 and older for one of the following eight ambulatory care–sensitive payments for graduate medical education and for treating low-income (ACS) conditions: long-term diabetes complications, lower extremity patients. Reimbursements reflect only the age 65 and older Medicare fee- amputation among patients with diabetes, asthma or chronic obstructive for-service population. Authors’ analysis of 2007-2013 Chronic Conditions pulmonary disease, hypertension, congestive heart failure, dehydration, Warehouse (CCW) data, retrieved from the February 2015 CMS Geographic bacterial pneumonia, and urinary tract infection. Authors’ analysis of Variation Public Use File (CMS, Office of Information Products and 2007-2013 Chronic Conditions Warehouse (CCW) data, retrieved from the Analytics (OPIDA) 2015). 43 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org Appendix exhibit h1. Scorecard Indicator Descriptions and Source Notes (continued) 32. Mortality amenable to health care, deaths per 100,000 population: 33. Years of potential life lost before age 75: Robert Wood Johnson Number of deaths before age 75 per 100,000 population that resulted from Foundation analysis of National Vital Statistics System Mortality Data, causes considered at least partially treatable or preventable with timely 2012 and 2013, using the Centers for Disease Control and Prevention and appropriate medical care (see list), as described in Nolte and McKee (CDC) National Center for Injury Prevention and Control Web-based Injury (Nolte and McKee, BMJ 2003). Authors’ analysis of mortality data from Statistics Query and Reporting System (WISQARS). Retrieved September CDC restricted-use Multiple Cause-of-Death file and U.S. Census Bureau 2015 from Robert Wood Johnson Foundation National DataHub. (NVSS population data, 2004-2013 (NCHS, MCD n.d.). 2012 and 2013). Causes of death Age 34. Breast cancer deaths per 100,000 female population: Authors’ Intestinal infections................................................................................0–14 analysis of NVSS–Mortality Data, 2012 and 2013 (NCHS, NVSS n.d.), retrieved using the CDC Wide-ranging OnLine Data for Epidemiologic Tuberculosis............................................................................................0–74 Research (WONDER) (NVSS 2012 and 2013). Other infections (diphtheria, tetanus, septicaemia, poliomyelitis)..........0–74 35. Colorectal cancer deaths per 100,000 population: Authors’ analysis Whooping cough.....................................................................................0–14 of NVSS–Mortality Data, 2012 and 2013 (NCHS, NVSS n.d.), retrieved using Measles....................................................................................................1–14 the CDC Wide-ranging OnLine Data for Epidemiologic Research (WONDER) (NVSS 2012 and 2013). Malignant neoplasm of colon and rectum...........................................0–74 36. Suicide deaths per 100,000 population: Authors’ analysis of NVSS– Malignant neoplasm of skin..................................................................0–74 Mortality Data 2012 and 2013 (NCHS NVSS), retrieved using the CDC Wide- Malignant neoplasm of breast..............................................................0–74 ranging OnLine Data for Epidemiologic Research (WONDER) (NVSS 2012 Malignant neoplasm of cervix uteri......................................................0–74 and 2013). Malignant neoplasm of cervix uteri and body of uterus....................0–44 37. Infant mortality, deaths per 1,000 live births: Authors’ analysis of Malignant neoplasm of testis................................................................0–74 National Vital Statistics System–Linked Birth and Infant Death Data, 2012 and 2013 (NCHS, NVSS), retrieved using the CDC Wide-ranging OnLine Data Hodgkin’s disease...................................................................................0–74 for Epidemiologic Research (WONDER) (NVSS 2012 and 2013). Leukemia.................................................................................................0–44 38. Percent of adults ages 18–64 report being in fair or poor health, or Diseases of the thyroid..........................................................................0–74 who have activity limitations because of physical, mental, or emotional Diabetes mellitus....................................................................................0–49 problems: Authors’ analysis of 2013 and 2014 Behavioral Risk Factor Surveillance System (NCCDPHP, BRFSS 2013, 2014). Epilepsy....................................................................................................0–74 Chronic rheumatic heart disease..........................................................0–74 39. Percent of adults who smoke: Percent of adults age 18 and older who ever smoked 100+ cigarettes (five packs) and currently smoke every day Hypertensive disease.............................................................................0–74 or some days. Authors’ analysis of 2013 and 2014 Behavioral Risk Factor Cerebrovascular disease........................................................................0–74 Surveillance System (NCCDPHP, BRFSS 2013, 2014). All respiratory diseases (excluding pneumonia and influenza)........1–14 40. Percent of adults ages 18-64 who are obese (Body Mass Index Influenza..................................................................................................0–74 [BMI] ≥ 30): Authors’ analysis of 2013 and 2014 Behavioral Risk Factor Surveillance System (NCCDPHP, BRFSS 2013, 2014). Pneumonia..............................................................................................0–74 41. Children (ages 10–17) who are overweight or obese (Body Mass Peptic ulcer..............................................................................................0–74 Index [BMI] ≥ 85th percentile): Overweight is defined as an age- and Appendicitis.............................................................................................0–74 gender-specific body mass index (BMI-forage) between the 85th and 94th Abdominal hernia...................................................................................0–74 percentile of the CDC growth charts. Obese is defined as a BMI-for-age at or above the 95th percentile. BMI was calculated based on parent-reported Cholelithiasis and cholecystitis............................................................0–74 height and weight. For more information, see www.nschdata.org. Data Nephritis and nephrosis.........................................................................0–74 from the National Survey of Children’s Health, assembled by the Child and Benign prostatic hyperplasia.................................................................0–74 Adolescent Health Measurement Initiative (CAHMI, NCHS 2011/2012). Maternal death........................................................................................All 42. Percent of adults ages 18–64 who have lost 6 or more teeth due to tooth decay, infection, or gum disease: Authors’ analysis of 2012 Congenital cardiovascular anomalies..................................................0–74 and 2014 Behavioral Risk Factor Surveillance System (NCCDPHP, BRFSS Perinatal deaths, all causes, excluding stillbirths...............................All 2012, 2014). Misadventures to patients during surgical and medical care...........All Ischaemic heart disease: 50% of mortality rates included................0–74 44 | Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition commonwealthfund.org The COMMONWEALTH FUND Affordable, quality health care. For everyone. www.commonwealthfund.org One East 75th Street 1150 17th Street NW New York, NY 10021 Suite 600 Tel 212.606.3800 Washington, DC 20036 Tel 202.292.6700