E R IG H G H IN A IM Results from a Scorecard on State Health System Performance, 2014 DAVID C. RADLEY, DOUGLAS MCCARTHY, JACOB A. LIPPA, SUSAN L. HAYES, AND CATHY SCHOEN MAY 2014 The COMMONWEALTH FUND This digital document was revised June 23, 2014, correcting several errors in exhibits 12, 13, 14, and 15. t h e c o m m o n w e a l t h f u n d , among the first private foundations started by a woman philanthropist— Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. The COMMONWEALTH FUND A I M I N G H I G H ER Results from a Scorecard on State Health System Performance, 2014 DAVID C. RADLEY, DOUGLAS MCCARTHY, JACOB A. LIPPA, SUSAN L. HAYES, AND CATHY SCHOEN MAY 2014 ABSTRACT The Commonwealth Fund’s Scorecard on State Health System Performance, 2014, assesses states on 42 indicators of health care access, quality, costs, and outcomes over the 2007–2012 period, which includes the Great Recession and precedes the major coverage expansions of the Affordable Care Act. Changes in health system performance were mixed overall, with states making progress on some indicators while losing ground on others. In a few areas that were the focus of national and state attention—childhood immunizations, hospital readmissions, safe prescribing, and cancer deaths— there were widespread gains. But more often than not, states exhibited little or no improvement. Access to care deteriorated for adults, while costs increased. Persistent disparities in performance across and within states and evidence of poor care coordination highlight the importance of insurance expansions, health care delivery reforms, and payment changes in promoting a more equitable, high- quality health system. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. no. 1743. CONTENTS List of Exhibits 5 About the Authors 6 Acknowledgments6 Overview7 Scorecard Findings in Detail 15 Implications 29 Scorecard Methodology 31 Notes 32 Appendices35 LIST OF EXHIBITS Overview Exhibit 1 Change in State Health System Performance by Indicator Exhibit 2 List of 42 Indicators in the Scorecard on State Health System Performance, 2014 Exhibit 3 State Scorecard Summary of Health System Performance Across Dimensions Exhibit 4 Overall State Health System Performance: Scorecard Ranking, 2014 Scorecard Findings in Detail Exhibit 5 Number of Indicators Improved or Worsened by State Exhibit 6 Children Ages 19–35 Months Who Received All Recommended Doses of even Vaccines, S 2009 vs. 2012 Exhibit 7 Medicare Beneficiaries Who Received a High-Risk Prescription edication, 2007 vs. 2011 M Exhibit 8 Medicare Cost per Beneficiary and 30-Day Readmissions by State, 2012 Exhibit 9 30-Day Readmissions and Potentially Avoidable Hospital Admissions mong Medicare A Beneficiaries, 2012 Exhibit 10 Mortality Amenable to Health Care Exhibit 11 Uninsured Adults and Children, 2011–12 Exhibit 12 Percent of Adults Who Went Without Care Because of Cost, 2007 vs. 2012 Exhibit 13 State Variation: Child Health Indicators, 2012 Exhibit 14 Change in Employer-Sponsored Insurance Premiums and edicare Spending, M 2008 to 2012 Exhibit 15 Change in Equity Dimension Performance by Indicator Exhibit 16 Mortality Amenable to Health Care by Race, State Variation, 2009–10 www.commonwealthfund.org5 ABOUT THE AUTHORS David C. Radley, Ph.D., M.P.H., is senior scientist and project director for The Commonwealth Fund’s Health System Scorecard and Research Project, a team based at the Institute for Healthcare Improvement in Cambridge, Mass. 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. Douglas McCarthy, M.B.A., serves as senior research director for The Commonwealth Fund, where he oversees The Commonwealth Fund’s Health System Scorecard and Research Project, conducts case-study research on delivery system reforms and breakthrough opportunities, and serves as a contributing editor to the bimonthly newsletter Quality Matters. 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. Jacob A. Lippa, M.P.H., is former senior research associate for The Commonwealth Fund’s Health System Scorecard and Research Project at the Institute for Healthcare Improvement in Cambridge, Mass. He had primary responsibility for conducting analytic work to update the ongoing series of health system scorecard reports. He managed data collection and analysis and served as coauthor both of reports and other related analyses for publication. Prior to joining the Fund, Mr. Lippa was senior research analyst at HealthCare Research, Inc., in Denver, where for more than six years he designed, executed, and analyzed customized research for health care payer, provider, and government agency clients. Mr. Lippa graduated from the University of Colorado at Boulder and received a master of public health degree with a concentration in health care policy and management from Columbia University’s Mailman School of Public Health. Susan L. Hayes, M.P.A., is research associate for Policy, Research, and Evaluation in The Commonwealth Fund’s New York office. Ms. Hayes also works closely with the Fund’s Scorecard team in Boston. Ms. Hayes joined the Fund after completing the Master in Public Administration program at New York University’s Wagner School of Public Service where she specialized in health policy, with extensive coursework in economics and policy analysis, and she won the Martin Dworkis Memorial Award for academic achievement and public service. Ms. Hayes 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. Cathy Schoen, M.S., is senior vice president at The Commonwealth Fund and a member of the Fund’s executive management team. Her work includes strategic oversight of surveys, research, and policy initiatives to track health system performance. Previously, Ms. Schoen was on the research faculty of the University of Massachusetts School of Public Health and directed special projects at the UMass Labor Relations and Research Center. During the 1980s, she directed the Service Employees International Union’s research and policy department. Earlier, she served as staff to President Carter’s national health insurance task force. Prior to federal service, she was a research fellow at the Brookings Institution. She has authored numerous publications on health policy and insurance issues, and national/international health system performance, including the Fund’s 2006 and 2008 National Scorecards on U.S. Health System Performance and the 2007 and 2009 State Scorecards, and coauthored the book Health and the War on Poverty. She holds an undergraduate degree in economics from Smith College and a graduate degree in economics from Boston College. 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., Arnold M. Epstein, M.D., M.A., 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 are grateful to the experts who shared background for the state case studies: Joseph W. Thompson, M.D., M.P.H., Arkansas Center for Health Improvement; Gretchen Hammer and Aubrey Hill, Colorado Coalition for the Medically Underserved; and Edie Sohn, Jonathan Mathieu, and Alicia Goroski, Center for Improving Value in Health Care. We would also like to thank the following Commonwealth Fund staff: David Blumenthal, Donald Moulds, Rachel Nuzum, and Anthony Shih (The New York Academy of Medicine, formerly of The Commonwealth Fund) for providing constructive guidance throughout; and the Fund’s communications team, including Barry Scholl, Chris Hollander, Deborah Lorber, Mary Mahon, Christine Haran, Josh Tallman, Suzanne Augustyn, 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. 6 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 OVERVIEW care experience across and within states. These The mixed performance of states’ health systems findings together suggest that the return on our over the five years preceding implementation of nation’s health care investment is falling woefully the Affordable Care Act’s major reforms sends a short. clear message that states and the nation are still a The Scorecard also reminds us, however, that long way from becoming places where everyone that improvement is possible with determined, has access to high-quality, affordable care and coordinated efforts. The most pervasive gains in an equal opportunity for a long and healthy life. health system performance between 2007 and In tracking 42 measures of health care access, 2012 occurred when policymakers and health quality, costs, and outcomes between 2007 and system leaders created programs, incentives, 2012 for the 50 states and the District of Columbia, and collaborations to raise rates of children’s The Commonwealth Fund’s Scorecard on State immunization, improve hospital quality, and lower Health System Performance, 2014, finds that, on a hospital readmissions (Exhibit 1). These gains significant majority of measures, the story is mostly illustrate that state health system performance one of stagnation or decline. In most parts of the reflects a confluence of national policy and state and country, performance worsened on nearly as many local initiatives that together can make a difference measures as it improved. for state residents. On a positive note, the Scorecard also shows that Like earlier scorecards in this series, the 2014 combined national and state action has the potential State Scorecard tracks and compares health care to promote performance gains across the country. experiences across the states and recent trends in Yet the improvements uncovered in the Scorecard key areas of performance to help policymakers and are not as widespread as Americans should expect, health system leaders identify opportunities for given the high level of resources the nation devotes improvement (Exhibit 2). In comparing the level to health care. of performance in each state to that in the top- During the Scorecard’s time frame, a period performing states, it offers attainable benchmarks. that encompassed the Great Recession, health care Moreover, the Scorecard documents the trajectory spending rose $491 billion, reaching $2.8 trillion of states’ health system performance in the years nationally according to government estimates.1 leading up to the Affordable Care Act’s major Spending increased in all states on both a per-capita insurance coverage reforms, which will allow us to basis and as a share of total state income. And still, track in future editions how state and local policy the Scorecard points to deteriorating access to care and care system responses to health reform may for adults, stagnant or worsening performance alter this trajectory in the future. (See Scorecard on other key measures such as preventive care for Methodology, page 31, for a detailed description of adults, and widespread disparities in peoples’ health the Scorecard’s methods and performance indicators.) www.commonwealthfund.org7 Exhibit 1. Change in State Health System Performance by Indicator Indicator Number of States that: (arranged by number of states with improvement within dimension) Improveda No Change Worseneda Access and Affordability 0 Children ages 0–18 uninsured 17 28 6 At-risk adults without a doctor visit 14 26 11 Adults without a dental visit in past year 7 26 18 Adults ages 19–64 uninsured 31 20 Adults who went without care because of cost in the past year 9 42 Prevention and Treatment Children ages 19–35 months with all recommended vaccines 51 Elderly patients who received a high-risk prescription drug 49 2 Hospital discharge instructions for home recovery 48 21 Patient-centered hospital care 48 21 Medicare patients experienced good communication with their provider 35 8 7 Children who received needed mental health care in the past year 14 17 20 Older adults with recommended preventive care 7 14 30 b Hospital 30-day mortality 5 32 14 Elderly patients who received a contraindicated prescription drug 2 26 23 Children with a medical home 1 23 27 Adults with a usual source of care 26 25 Avoidable Hospital Use and Cost Medicare admissions for ACS conditions, age 75 and older* 45 6 Medicare admissions for ACS conditions, ages 65–74* 41 10 Medicare 30-day hospital readmissions, per 1,000 beneficiaries 38 13 Hospital admissions for pediatric asthma, per 100,000 children 16 17 3 Long-stay nursing home residents with a hospital admission 3 44 1 Short-stay nursing home residents with a 30-day readmission to the hospital 2 39 7 Total Medicare (Parts A & B) reimbursements per enrollee 12 39 Health insurance premium for employer-sponsored single-person plans 51 Healthy Lives Colorectal cancer deaths per 100,000 population 44 5 2 Breast cancer deaths per 100,000 female population 35 12 4 Mortality amenable to health care 25 26 Years of potential life lost before age 75 18 33 Children who are overweight or obese 18 19 14 Infant mortality, deaths per 1,000 live births 14 35 2 Adults who smoke 13 28 10 Adults who are obese 3 23 25 Adults who have lost six or more teeth 1 40 10 Suicide deaths per 100,000 population 33 18 Adults with poor health-related quality of life 10 41 Notes: Trend data generally reflect the five-year period ending in 2011 or 2012; refer to Appendix B for additional detail. Based on trends for 34 of 42 total indicators (* ACS = ambulatory care–sensitive—ACS conditions among Medicare beneficiaries are displayed here separately for two age ranges, but counted as a single indicator in tallies of improvement). Trend data are not available for all indicators. (a) Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. (b) Risk-adjusted 30-day mortality among Medicare beneficiaries with heart attack, congestive heart failure, or pneumonia. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 8 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Key Findings of premature death (mortality amenable to In assessing change over the five years leading up to health care and years of potential life lost), but 2011–12, the Scorecard reveals persistent geographic even greater progress may be possible through disparity in the performance of state health care health system improvement. systems as well as variation in rates of change. These • States lost ground in insurance coverage for variations may partly reflect differences in state adults and affordability of care. As a consequence, policies and funding of health care programs such a greater number of adults in 42 states reported as Medicaid, as well as in local norms and practices going without care because of its cost—a trend (Exhibits 3 and 4). Several themes stand out: that likely reflects lingering effects of the 2007– 2009 recession. There were some improvements in state health system performance in recent years, but wide- • Health care spending continued to rise, but to spread gains remained the exception. a greater degree in the private market than in • On two-thirds of the 34 Scorecard indicators Medicare, which saw a historic moderation in for which longitudinal data exist, there was spending. no meaningful improvement or decline in performance in most states. On nine of the Troubling disparities and gaps in care persisted 34, meaningful improvement occurred in a for children and other vulnerable populations. majority of the states (Exhibit 1).* A few states • For children, changes in health system (Colo., Md., N.H., and N.Y.) stand out for their performance were mixed. There have been net improvement across indicators (Appendix some promising gains in recent years, such Exhibit A1). as a lower rate of asthma hospitalizations. But troubling declines on other health care • Most states improved on indicators that have indicators, such as the proportion of children been the focus of national and state attention, with a primary care “medical home,” emphasize including immunizations for children, safe the need for continued diligence to secure the prescribing of medications for the elderly, health of future generations. patient-centered care in the hospital, avoidable hospital admissions and readmissions, and • Disparities in health care and outcomes cancer-related deaths. remained wide between vulnerable and more- advantaged groups within all states. While • Lower premature mortality rates, including states made progress in reducing disparities lower rates of cancer-related death, suggest that in premature mortality and certain other key improvements in medical care are contributing Scorecard indicators, disparities also widened to better health outcomes. Fifteen states saw for others, such as poor health-related quality meaningful reductions on each of two measures of life. * Changes in an indicator’s value between the historical and current year data points are considered to be meaningful if they were at least one half (0.5) of a standard deviation larger than the indicator’s distribution over the two time points. One indicator—hospitalizations for ambulatory care–sensitive conditions among Medicare beneficiaries—was measured for two age subpopulations: those ages 65 to 74, and those age 75 and older. We consider these a single measure for purposes of scoring and tallying state improvement counts. Refer to the Scorecard Methodology on page 31 for additional information. www.commonwealthfund.org9 List of 42 Indicators in the Scorecard on State Health System Performance, 2014 U.S. Average Rate Range of State Performance 2014 Scorecard Revised 2009 2014 Revised 2009 2014 Indicator Scorecarda Scorecard Scorecarda Scorecard Best State(s)b ACCESS AND AFFORDABILITY DIMENSION SUMMARY 1 Adults ages 19–64 uninsured 19 21 7–31 5–32 MA 2 Children ages 0–18 uninsured 10 10 3–20 3–20 MA 3 Adults who went without care because of cost in past year 13 17 6–19 9–22 HI, MA, ND Individuals under age 65 with high out-of-pocket medical costs 4 —c 16 —c 10–22 DC, MN relative to their annual household income 5 At-risk adults without a routine doctor visit in past two years 14 14 7–23 6–23 DE, MA 6 Adults without a dental visit in past year 15 15 9–20 10–20 NH PREVENTION AND TREATMENT DIMENSION SUMMARY 7 Adults with a usual source of care 80 78 72–90 63–89 MA Adults age 50 and older who received recommended screening and 8 44 42 36–52 34–52 MA preventive care 9 Children with a medical home 58 54 45–69 45–69 VT 10 Children with a medical and dental preventive care visit in the past year —c 68 —c 56–81 VT Children with emotional, behavioral, or developmental problems who 11 60 61 42–81 40–86 ND received needed mental health care in the past year Children ages 19–35 months who received all recommended doses of 12 44 68 23–59 60–80 HI, NH seven key vaccines Medicare beneficiaries who received at least one drug that should be 13 29 20 16–44 12–29 MA, VT avoided in the elderly Medicare beneficiaries with dementia, hip/pelvic fracture, or chronic renal fail- 14 20 23 14–27 14–29 ME ure who received a prescription drug that is contraindicated for that condition Medicare fee-for-service patients whose health provider always listens, 15 75 76 69–78 72–80 LA explains, shows respect, and spends enough time with them Risk-adjusted 30-day mortality among Medicare beneficiaries hospitalized 16 12.7 12.7 11.8–14.1 11.9–13.6 MA for heart attack, heart failure, or pneumonia Hospitalized patients given information about what to do during their 17 79 83 73–87 77–89 UT recovery at home Hospitalized patients who reported hospital staff always managed pain well, 18 responded when needed help to get to bathroom or pressed call button, 62 66 52–69 57–71 LA, SD and explained medicines and side effects 19 Home health patients who get better at walking or moving around —c 59 —c 49–63 AL, FL, MS, UT 20 Home health patients whose wounds improved or healed after an operation —c 89 —c 81–95 DC 21 High-risk nursing home residents with pressure sores —c 6 —c 3–9 HI 22 Long-stay nursing home residents with an antipsychotic medication —c 22 —c 12–29 HI 10 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 List of 42 Indicators in the Scorecard on State Health System Performance, 2014 (continued) U.S. Average Rate Range of State Performance 2014 Scorecard Revised 2009 2014 Revised 2009 2014 Indicator Scorecarda Scorecard Scorecarda Scorecard Best State(s)b AVOIDABLE HOSPITAL USE AND COST DIMENSION SUMMARY 23 Hospital admissions for pediatric asthma, per 100,000 children 156 130 43–284 26–223 VT Hospital admissions for ambulatory care–sensitive conditions per 1,000 beneficiaries: 24 Medicare beneficiaries ages 65–74 36 29 20–56 13–50 HI Medicare beneficiaries age 75 and older 85 70 46–119 41–100 HI 25 Medicare 30-day hospital readmissions, rate per 1,000 beneficiaries 58 49 29–74 26–65 HI, ID Short-stay nursing home residents readmitted within 30 days of hospital 26 20 20 13–24 12–26 UT discharge to nursing home 27 Long-stay nursing home residents hospitalized within a six-month period 19 19 7–32 7–31 MN 28 Home health patients also enrolled in Medicare with a hospital admission —c 17 —c 14–19 UT Potentially avoidable emergency department visits among Medicare 29 —c 185 —c 129–263 HI beneficiaries, per 1,000 beneficiaries Total single premium per enrolled employee at private-sector establishments 30 $4,452 $5,431 $3,300–$5,967 $4,180–$7,177 CA that offer health insurance 31 Total Medicare (Parts A & B) reimbursements per enrollee $8,336 $8,874 $5,149–$10,573 $5,406–$10,873 AK HEALTHY LIVES DIMENSION SUMMARY 32 Mortality amenable to health care, deaths per 100,000 population 96 86 64–158 57–136 MN 33 Years of potential life lost before age 75 7,153 6,474 5,198–12,276 4,900–9,781 MN 34 Breast cancer deaths per 100,000 female population 24.2 22.1 17.9–29.2 14.8–29.9 HI 35 Colorectal cancer deaths per 100,000 population 17.7 15.8 13.4–21 12–20.5 UT 36 Suicide deaths per 100,000 population 10.9 12.1 5.4–21.7 6.9–22.8 DC 37 Infant mortality, deaths per 1,000 live births 6.8 6.4 4.4–12.2 4.6–10.4 IA, MN Adults ages 18–64 who report fair/poor health or activity limitations 38 24 27 17–31 19–36 ND because of physical, mental, or emotional problems 39 Adults who smoke 19 19 12–28 10–28 UT 40 Adults ages 18–64 who are obese (BMI >= 30) 26 28 20–34 21–37 CO 41 Children ages 10–17 who are overweight or obese (BMI >= 85th percentile) 32 31 23–44 22–40 UT Percent of adults ages 18–64 who have lost six or more teeth because of 42 10 10 5–20 5–23 UT tooth decay, infection, or gum disease Notes: (a) Several indicators have changed since the 2009 State Scorecard. The revised 2009 Scorecard ranking generally reflects the period five years prior to the time of observation for the latest year of data available, though this varies by indicator. (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. www.commonwealthfund.org11 Exhibit 3. State Scorecard Summary of Health System Performance Across Dimensions Performance Quartile Top Quartile Second Quartile t st os Co C Third Quartile & & t t se se en en Bottom Quartile y y lU lU tm tm lit lit bi bi ita ita ea ea da da sp sp Tr Tr or or Ho Ho es es & & Aff Aff iv iv n n e e tio tio yL yL bl bl & & 2014 Scorecard Ranking Revised 2009 Scorecard da da en en th th ss ss ty ty ce ce oi al al oi ev ev ui ui Ranking* He He Av Av Eq Eq Ac Ac Pr Pr 1 Minnesota 1 1 1 1 1 Minnesota 1 1 1 1 1 2 Massachusetts 1 1 3 1 1 2 Hawaii 2 2 1 1 1 2 New Hampshire 1 1 1 1 1 2 Massachusetts 1 1 3 1 1 2 Vermont 1 1 1 1 1 2 Vermont 1 1 1 1 1 5 Hawaii 2 2 1 1 1 5 Connecticut 1 1 2 1 1 6 Connecticut 1 1 3 1 1 5 New Hampshire 1 1 2 2 1 7 Maine 1 1 2 2 1 5 Rhode Island 1 1 2 1 1 7 Wisconsin 1 1 2 2 1 8 Iowa 1 1 2 1 1 9 Rhode Island 1 1 2 1 1 9 Maine 1 1 2 2 1 10 Delaware 1 1 2 3 1 9 North Dakota 1 2 1 2 1 10 Iowa 1 1 2 2 2 9 Wisconsin 1 1 2 1 1 12 Colorado 3 1 1 1 2 12 South Dakota 2 2 1 3 2 12 South Dakota 2 2 1 2 2 13 Delaware 1 1 2 3 2 14 North Dakota 1 2 2 3 2 14 Pennsylvania 1 1 3 3 1 15 New Jersey 2 2 3 1 2 15 Colorado 3 1 1 1 4 15 Washington 2 3 1 1 2 15 Michigan 2 1 4 3 1 17 Maryland 2 2 3 2 1 17 Nebraska 2 3 2 2 3 17 Nebraska 2 1 2 1 3 18 New York 2 2 3 2 1 19 New York 2 3 3 1 1 18 Washington 2 3 1 1 3 19 Utah 4 3 1 1 2 20 Kansas 2 2 3 2 2 21 District of Columbia 1 2 4 3 1 20 Montana 4 3 1 2 2 22 Pennsylvania 2 1 3 3 1 20 Utah 3 3 1 1 4 23 Kansas 2 2 3 2 3 23 New Jersey 2 2 3 2 2 24 Oregon 3 3 1 2 3 24 District of Columbia 1 2 4 3 2 24 Virginia 2 3 3 2 3 24 Maryland 2 2 4 3 3 26 California 3 4 2 1 3 24 Oregon 3 3 1 2 3 26 Illinois 2 2 4 3 2 27 Alaska 4 2 1 3 3 26 Michigan 2 1 4 3 2 27 Virginia 2 3 2 2 4 29 Montana 4 3 1 2 4 29 California 3 4 1 1 3 29 Wyoming 3 2 2 3 3 30 Wyoming 3 3 2 2 3 31 Alaska 3 4 1 3 3 31 Indiana 2 3 3 3 2 31 Idaho 4 3 1 2 4 31 Ohio 2 2 4 4 3 31 Ohio 2 2 4 4 2 33 Idaho 4 4 1 2 4 34 Missouri 3 3 4 4 3 34 West Virginia 3 2 4 4 2 34 West Virginia 3 2 4 4 2 35 Georgia 3 4 3 3 3 36 Arizona 4 4 2 2 4 35 Illinois 3 3 4 3 3 36 New Mexico 4 4 1 3 3 35 Missouri 3 3 3 4 2 36 North Carolina 3 3 3 3 4 35 New Mexico 4 4 1 3 3 36 South Carolina 4 2 2 4 3 39 South Carolina 4 3 2 4 3 40 Tennessee 3 3 4 4 3 40 Arizona 4 4 2 3 4 41 Florida 4 3 3 2 4 40 Florida 3 3 3 3 3 42 Kentucky 3 2 4 4 3 40 Kentucky 3 3 4 4 2 43 Indiana 3 3 4 4 4 43 Tennessee 3 3 4 4 2 44 Texas 4 4 3 3 4 44 Alabama 3 2 4 4 4 45 Georgia 4 4 3 3 4 44 North Carolina 4 3 3 4 4 46 Alabama 3 3 4 4 3 46 Nevada 4 4 2 4 4 46 Nevada 4 4 2 3 4 47 Texas 4 4 3 2 4 48 Louisiana 4 4 4 4 3 48 Louisiana 4 4 4 4 4 49 Oklahoma 3 4 4 4 4 49 Arkansas 4 4 4 4 4 50 Arkansas 4 4 3 4 4 50 Oklahoma 4 4 4 4 4 51 Mississippi 4 4 4 4 4 51 Mississippi 4 4 4 4 4 Note: Several indicators have changed since the 2009 State Scorecard. Therefore, the 2009 Scorecard ranking has been revised to reflect the addition of several new indicators and updated definitions for others. The revised 2009 Scorecard ranking generally reflects the period five years prior to the time of observation for the latest year of data available, though this varies by indicator. If historical data were not available for a particular indicator, the most current year of data available were used as a substitute in the revised 2009 Scorecard ranking. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 12 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Widespread geographic variations in health sys- time (Exhibits 3 and 4). Their consistently tem performance persist, providing benchmarks high performance may be the result of their and illustrating opportunities to do better. willingness and wherewithal to address health • There were two-to-eightfold gaps between system change with focused initiatives spanning leading and lagging states on multiple the public and private sectors. indicators of health care access, quality, • Opportunities for improvement abound. Even prevention, costs, and outcomes (Exhibit 2). leading states did not perform consistently • Although the range between top- and bottom- well—or consistently improve—across all performing states remained wide on most performance indicators. indicators, the gap narrowed for several of the key indicators on which there was also widespread state improvement—illustrating How National Policies Combined with that lagging states can close the gap, even as top State and Local Action Can Spur Better states improve. Performance It is notable that those indicators in which more • The top-performing states—Minnesota, than half the states improved have been the focus of Massachusetts, New Hampshire, Vermont, national as well as state policy and attention. Health and Hawaii—lead the nation across most care gains for Medicare beneficiaries in the quality dimensions of care, and have done so over and use of hospital care occurred in the majority Exhibit 4. Overall State Health System Performance: Scorecard Ranking, 2014 WA MT ME ND OR MN VT ID NH SD WI NY MA MI CT WY RI IA PA NE NJ NV OH IL IN DE UT MD CA CO WV KS MO VA KY DC NC TN AZ OK NM AR SC Overall performance, 2014 MS AL GA Top quartile (13 states) TX LA Second quartile (11 states + D.C.) FL Third quartile (14 states) AK Bottom quartile (12 states) HI Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org13 of states, providing a platform for further state and should support broader improvements in quality of local action. States can build on national policy—as care and health status.3 they did by expanding children’s coverage through It is possible, however, that geographic the federal–state Children’s Health Insurance disparities in performance will widen, and health Program—to influence health system performance care inequities within states worsen, if such health in many ways, such as by promoting accountable system reforms and innovations are not evenly care in Medicaid and value-based purchasing of spread across states. Throughout this report, we coverage for state employees and by supporting demonstrate that better access to care is associated collaboration among public and private stakeholders with better primary and preventive care services to consistently measure and improve care. and improved health outcomes. To the extent that some states take the lead in expanding health coverage—through Medicaid and high-quality Looking Toward the Future private insurance choices in the new marketplaces— Findings from the Scorecard on State Health System while other states lag, we may see a widening rather Performance, 2014, signal both promise and caution than a narrowing of health outcomes and quality of for the future. Massachusetts’ experience with care. Conversely, if many states seize on new federal insurance coverage expansion suggests that cost- opportunities and flexibility for creative action and related barriers to care should ease for individuals learn from each other, we could hope for accelerated and families who gain coverage under the gains in the years ahead. Affordable Care Act.2 This increased access, in turn, Visit The Commonwealth Fund’s website to view a comprehensive set of online tools, including state-specific data, state profiles with time trends, benchmarking tools, and a supplemental chart pack with additional Scorecard findings. The Scorecard methods are described in the Scorecard Methodology on page 31, and the Appendix tables provide detailed state-level data by dimension and indicator, as well as indicator definitions and data sources. 14 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 SCORECARD FINDINGS IN DETAIL 8.8 million in 2007–08 to 7.4 million in 2011–12. Seventeen states saw at least a 2 percentage point Performance failed to improve in a meaningful reduction in uninsured children (Exhibit 1). And, way for most states on two-thirds of the indica- in a time when the economic recession might have tors for which trend data exist. otherwise exacted a greater toll, only six states saw Overall, among the 34 indicators with time trends an increase. in the Scorecard on State Health System Performance As a nation, we have also made strides to 2014, there was a meaningful improvement among ensure that young children receive recommended a majority of states on only nine indicators. All vaccines. Cooperative initiatives such as the states saw meaningful improvement on at least Centers for Disease Control and Prevention’s seven of the 34 indicators with time trends, but no Vaccines for Children Program enable partnership state improved on more than half of the indicators between federal and state governments, primary and all states experienced declining performance on care physicians, and public health agencies to at least four indicators (Exhibit 5). support widespread vaccination.5 Despite a national In most states, performance worsened on almost shortage in one vaccine (Haemophilus influenzae as many indicators as it improved. A few states stand type b) that reduced overall vaccination rates from out for achieving the greatest net improvement late 2007 to early 2009,6 the share of young children across indicators: Colorado, Maryland, New (ages 9 months to 35 months) who received all Hampshire, and New York. Their experiences may recommended vaccines7 rose dramatically after the offer lessons for other states on how to reach a shortfall ended, both nationally and in each state, tipping point of change. Unfortunately, in several from 2009 to 2012—even as a new vaccine was states, performance declined on as many or more added to the schedule (Exhibit 6). indicators than it improved (Appendix Exhibit A1). Efforts to improve the quality of ambulatory care Despite a few bright spots, the Scorecard’s have not received the same level of national attention findings point more toward stagnation in health and public accountability given to improving care system performance across states over the past in hospitals. Still, there were several bright spots. five years, rather than clear and widespread In 35 states, more Medicare beneficiaries reported improvement. having better communications with their doctors in 2013 compared with 2007 (Exhibit 1). In addition, Many states improved on key indicators of nearly all states experienced a meaningful reduction health system performance that have been the in the share of elderly Medicare beneficiaries focus of national and state commitment, collab- orative effort, and expert attention. prescribed a high-risk medicine that should be While the 2014 Scorecard predates recent coverage avoided in older adults (Exhibit 7).8 Possibly expansions under the Affordable Care Act (ACA), contributing to this improvement were programs it does capture the impact of earlier federal–state to educate patients about their medications, such as policy action to expand coverage for children. In Medication Therapy Management Programs offered 2009, Congress reauthorized the State Children’s by Medicare prescription drug plans and some state Health Insurance Program (CHIP) with added Medicaid programs, as well as the increased use of support to cover more children from low-income electronically assisted prescribing and better clinical families.4 As a result, the number of uninsured decision support.9 children under age 18 fell by 1.4 million—from www.commonwealthfund.org15 Exhibit 5. Number of Indicators Improved or Worsened by State Number of Indicators Worsened Number of Indicators Improved 7 AK 11 16 AL 7 13 AR 12 7 AZ 13 7 CA 15 6 CO 16 10 CT 11 7 DC 10 7 DE 10 10 FL 13 12 GA 13 8 HI 9 7 IA 7 9 ID 10 6 IL 10 13 IN 7 8 KS 10 9 KY 12 11 LA 14 5 MA 12 4 MD 14 6 ME 10 12 MI 10 10 MN 10 11 MO 11 10 MS 11 11 MT 10 7 NC 15 11 ND 9 5 NE 12 6 NH 15 9 NJ 13 9 NM 11 12 NV 11 7 NY 16 11 OH 12 8 OK 12 9 OR 12 9 PA 11 14 RI 9 13 SC 13 9 SD 11 10 TN 12 7 TX 13 11 UT 9 8 VA 12 6 VT 12 7 WA 9 7 WI 11 13 WV 10 9 WY 10 Notes: Based on trends for 34 of 42 total indicators (ambulatory care–sensitive conditions among Medicare beneficiaries from two age groups are considered a single indicator in tallies of improvement). 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. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 16 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 In contrast, 23 states experienced an increase rates are declining in hospitals as well.11 Hospitals in the proportion of elderly patients who were are not only providing higher-quality clinical care: prescribed a drug contraindicated for a specific surveys indicate that patients’ experiences have medical condition (Exhibit 1). Such mixed results also improved across most states, albeit slowly highlight the need for a more consistent approach (Appendix Exhibit A6). to improving drug safety. Hospital readmissions are often an indication of Hospitals across the nation have made weak primary care, fragmented care, and failure to substantial gains in providing evidence-based coordinate care well during transitions. The result care, particularly for patients with heart attack, is higher costs, manifested as greater spending in congestive heart failure, and community-acquired states with higher readmission rates (Exhibit 8). pneumonia—three conditions at the center of Lowering readmissions has thus become a goal national quality reporting efforts tied to Medicare of federal and state payment policy, as well as of reimbursement. In 2004, not a single state reached private-sector quality improvement efforts.12 The 90 percent compliance on a composite measure of rate of 30-day readmissions per 1,000 Medicare care quality for these three conditions. By 2012, all beneficiaries fell substantially in 38 states between states were above 95 percent, with only 3 percentage 2008 and 2012 (Exhibits 1 and 9). During this points separating the top and bottom states.10 period there were focused efforts to reduce The federal government recently released readmissions, such as the federal Partnership data showing that health care–associated infection for Patients initiative, which set a goal to reduce Exhibit 6. Children Ages 19–35 Months Who Received All Recommended Doses of Seven Vaccines, 2009 vs. 2012 Percent 2012 2009 90 80 70 60 50 40 30 20 10 0 Washington Nevada Minnesota New Jersey District of Columbia Missouri Georgia Pennsylvania Utah Massachusetts Iowa Alaska Indiana Idaho Vermont South Dakota Texas Arkansas Montana Oregon Wyoming Arizona Kentucky Florida Illinois Louisiana Alabama Michigan Colorado New Mexico Maine Nebraska Tennessee North Carolina Wisconsin Connecticut Mississippi New York Kansas Ohio Virginia North Dakota South Carolina Hawaii New Hampshire Oklahoma California Maryland Rhode Island Delaware West Virginia Note: 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: 2009 and 2012 National Immunization Surveys (NIS). Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org17 Exhibit 7. Medicare Beneficiaries Who Received a High-Risk Prescription Medication, 2007 vs. 2011 Percent 50 2011 2007 45 40 35 30 25 20 15 10 5 0 Wyoming* Indiana* Louisiana* Missouri* Texas* Georgia* Massachusetts* Maine* Minnesota* New York* South Dakota* New Hampshire* North Dakota* Rhode Island* Illinois* Iowa* New Jersey* Pennsylvania* Maryland* Delaware* Nebraska* California* Colorado* Florida* Ohio* Washington* Kansas* Virginia* Nevada* Utah* New Mexico* West Virginia* Kentucky* Oklahoma* Tennessee* Alabama* Mississippi* Connecticut* Montana* Alaska* Arizona* Hawaii North Carolina* Vermont* Arkansas* Michigan* South Carolina* District of Columbia Oregon* Idaho* Wisconsin* Note: States are arranged in rank order based on their current data year (2011) value. States with at least a 0.5 standard deviation change (–4 percentage points) between 2007 and 2011 are denoted with (*). Data: 2007 and 2011 Medicare Part D 5% Sample. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. readmissions by 40 percent below 2010 levels within and heart failure. The largest declines (and a three years, as well as the ACA’s financial penalties narrowing in state variation) were seen among for “excess” readmissions, starting in October Medicare beneficiaries age 75 and older; modest 2012.13 Nationally, the readmission rate declined 16 declines were also seen among beneficiaries ages 65 percent, which translates to approximately 197,000 to 74 (Exhibit 9). There were no states where ACS fewer readmissions in 2012 than in 2008. Recently, hospitalization rates were higher in 2012 than in the federal government released preliminary data 2008. On the other hand, there is wide variation from 2013 showing that the ratio of readmissions among states: hospitalizations rates in 2012 were at to admissions has declined,14 as well as the rate least two-and-a-half times higher in Kentucky (the of admissions, indicating that attention to this state with the highest rate) than in Hawaii (the state problem is bearing fruit.15 (See Appendix Exhibit with the lowest rates) for both age cohorts. A8 for readmission rates as a percent of admissions The 65–74 age group remains one to watch as by state through 2012.) more members of the baby boomer generation Likewise, rates of hospitalizations for reach retirement age. Although changes in disease ambulatory care–sensitive conditions (ACS) among prevalence and risk factors may influence these elderly Medicare beneficiaries fell nationally and rates, the fact that they declined year-over-year in more than 40 states. These are conditions across states and in both age groups suggests that in which effective ambulatory care can reduce this trend reflects improvements in ambulatory care hospitalizations, like asthma, diabetes, pneumonia, management, supported by Medicare prescription 18 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Exhibit 8. Medicare Cost per Beneficiary and 30-Day Readmissions by State, 2012 $12,000 $11,000 LA FL Medicare reimbursement per enrollee TX MS $10,000 NJ OH AL IN PA KY TN MI OK IL DC $9,000 GA DE MO CT MA NY WV SC KS NE NV RI AR MD UT AZ NC $8,000 CA VA NH ME WI CO ID ND SD IA $7,000 NM WA MN MT VT WY OR R2 = 0.67 $6,000 HI AK $5,000 20 30 40 50 60 70 Medicare 30-day readmissions, rate per 1,000 beneficiaries Notes: Medicare spending estimates exclude prescription drug costs and reflect only the age 65+ Medicare FFS population. Estimates are 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. Data: Medicare claims via Dec. 2013 CMS Geographic Variation Public Use File. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. Exhibit 9. 30-Day Readmissions and Potentially Avoidable Hospital Admissions Among Medicare Beneficiaries, 2012 30-day readmissions Hospitalizations for ambulatory care– sensitive conditions 120 100 80 Lowest-performing 25% of states Ages 65–74 60 All states median 40 Highest-performing 25% of states Age 75 and older 20 0 2008 2012 2008 2012 2008 2012 Data: Medicare claims via Dec. 2013 IOM/CMS Geographic Variation Database. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org19 drug coverage16 that helps patients control chronic treated through early detection and high-quality conditions and risk factors such as high blood care. Nationally, rates fell 10 percent between pressure.17 If these positive trends continue, reduced 2004–05 and 2009–10. In 18 states, there were use of expensive hospital care could result in also meaningful declines in “years of potential life savings. And that could free up resources for health- lost”—a measure of premature deaths before age 75 promotion efforts in the community. that gives more weight to deaths at younger ages. Nationally, that rate fell 9 percent between 2005 and Reductions in premature mortality suggest 2010. Fifteen states saw meaningful improvement improvements in medical care are contributing on both indicators. to better health outcomes. In addition, breast and colon cancer mortality Two broad measures of premature mortality fell rates dropped substantially in the vast majority of in almost all states (Exhibit 1). In 25 states, there states, while infant mortality declined meaningfully were meaningful declines in mortality amenable to in 14 states. health care, a measure that captures deaths before As promising as these trends are, the U.S. has age 75 from conditions that can be effectively not achieved the same magnitude of reductions COLORADO: LEADING THE WAY TO HIGHER PERFORMANCE Colorado’s rising performance since the first edition of the State Scorecard reflects a collaborative spirit among providers, insurers, and community leaders in the state. With no single care delivery system or insurer dominating the market, there is an imperative for shared leadership. This spirit is evident in health plans’ and providers’ agreement to follow common clinical guidelines and jointly test i the patient-centered medical home as a means to enhance primary care and reduce unnecessary hospital use. It can also be seen in Western Colorado, which has garnered national attention for creating one of the first sustainable regional health information ex- ii changes, allowing physicians and hospitals to interconnect for better care coordination. Colorado’s relatively healthy population also contributes to the state’s performance, including the Scorecard’s indicators of avoidable hospital use. However, while Coloradans are known for their enthusiasm for the outdoors, the state faces health challenges similar to those faced elsewhere in the United States. In pursuit of the governor’s commitment to making the state the healthiest in the nation, Colorado benefits from the grantmaking activities of several state-based foundations that fund initiatives to improve access to care, promote healthy lifestyles, and advance health equity. A persistently high uninsured rate remains the Achilles’ heel of the state’s health care system. To address access and affordability, policy- makers in 2006 appointed the bipartisan Blue Ribbon Commission on Health Care Reform, which forged consensus on a “Colorado vision” for Medicaid and private insurance reforms. One of its notable achievements was enactment of a hospital provider fee, matched by federal funds, to improve access to care for low-income state residents by enhancing Medicaid reimbursement and expanding coverage. The state also took a proactive approach to implementing the Affordable Care Act, including the creation of a state-based health insurance exchange, building on the federal legislation as an opportunity to accomplish many of the reforms recommended by the Commission. iii These policy achievements were informed by an advocacy community that rallied political support for expanded children’s coverage and access for the uninsured. Colorado continues to innovate in other ways. For example, the state is instituting regional accountable care arrangements in its iv Medicaid program and fostering public–private partnerships to create an all-payer medical claims database. Although not all of these efforts had borne fruit during the period measured by the State Scorecard, they presage a hopeful future for a state that is defining its own way to higher performance. i M. G. Harbrecht and L. M. Latts, “Colorado’s Patient-Centered Medical Home Pilot Met Numerous Obstacles, Yet Saw Results Such as Reduced Hospital Admissions,” Health Affairs, Sept. 2012 31(9):2010–17. ii D. McCarthy and A. Cohen, The Colorado Beacon Consortium: Strengthening the Capacity for Health Care Delivery Transformation in Rural Communities (New York: The Commonwealth Fund, April 2013). iii Comparison of Provisions from Colorado’s Blue Ribbon Commission for Health Care Reform and Federal Health Care Reform (Denver: Colorado Trust, Oct. 2010). iv D. Rodin and S. Silow-Carroll, Medicaid Payment and Delivery Reform in Colorado: ACOs at the Regional Level (New York: The Commonwealth Fund, March 2013). 20 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Exhibit 10. Mortality Amenable to Health Care Deaths per 100,000 population 2004–05 2009–10 WA 160 MT ND ME VT OR MN 140 NH ID WI NY MA SD CT RI WY MI 120 IA PA NJ NE NV IN OH DE 100 UT IL CA CO WV VA MD KS MO KY DC 80 NC TN AZ OK NM AR SC 60 MS AL GA 40 TX LA AK 20 FL 0 Best Top 5 All-states Bottom 5 Bottom HI 57–67 (12 states) state states median states state average average 71–81 (13 states) 82–95 (14 states) 97–136 (11 states + D.C.) Note: Age-standardized deaths before age 75 from select causes. Mortality rates for the District of Columbia are excluded from the figure on the right. Data: 2004–05 and 2009–10 National Vital Statistics System (NVSS) mortality all-county micro data files. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. in mortality amenable to health care as have other States lost ground in key areas including access developed countries that ensure universal access to care, primary and preventive care, obesity, to health care.18 Moreover, although they declined, and health-related quality of life. rates of premature death remained highly variable Between 2007–08 and 2011–12, the years leading across states (Exhibit 10). Mortality amenable up to implementation of the ACA’s coverage to health care was more than twice as high in expansions, the number of uninsured adults Mississippi (136 per 100,000) in 2009–10 as it was swelled by 4.6 million, from 35.6 million to 40.2 in Minnesota (57 per 100,000). As we highlight million. The rate rose from 19 percent to 21 percent in more detail in the Equity section beginning on nationally, ranging from 5 percent in Massachusetts page 25, the rate was twice as high among blacks as to 32 percent in Texas in 2011–12. In 39 states and among whites in most states. Even among the white the District of Columbia, uninsured rates among population, state rates varied more than twofold, adults were at least double that of children in the from a low of 46 deaths per 100,000 in the District same state, including four states where they were of Columbia to a high of 106 per 100,000 in West triple (Exhibit 11). Despite the overall increase in Virginia (Appendix Exhibit A12). uninsured adults, uninsured rates have declined Although medical care is only one factor among young adults ages 19 to 26, many of whom contributing to population health outcomes, it is have become eligible for continued coverage encouraging that five of the six mortality measures through their parents’ health plans thanks to a improved in multiple states and that reductions provision of the ACA. Nationally, the uninsured rate were generally consistent year over year. Even in this age cohort is down from 31 percent in 2009 greater improvement may be possible by expanding to 28 percent in 2012.19 More recent national data coverage and reducing disparities. www.commonwealthfund.org21 Exhibit 11. Uninsured Adults and Children, 2011–12 Percent 35 Adults ages 19–64 Children ages 0–18 30 25 Adults uninsured, U.S. average = 21% 20 15 10 Children uninsured, U.S. average = 10% 5 0 Washington District of Columbia Nevada Minnesota New Jersey Missouri Massachusetts Georgia Iowa Pennsylvania North Carolina Utah Connecticut Vermont Maine Michigan Wisconsin Tennessee Illinois Oregon Indiana Alabama South Dakota Kentucky Nebraska Colorado Mississippi Arkansas Wyoming Louisiana Idaho Montana New Mexico Alaska Arizona Florida Texas Hawaii North Dakota New York Virginia New Hampshire Ohio Kansas Maryland South Carolina Oklahoma California Rhode Island Delaware West Virginia Note: States are arranged in rank order based on the proportion of uninsured children. Data: 2012–13 Current Populations Survey (CPS). Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. indicate the uninsured rate has begun to decline for Primary care is essential to efficient and all adults.20 effective health care systems, providing basic Not having health insurance coverage, or and preventive care, coordination, and a gateway having insurance that does not provide adequate to more specialized services.21 Yet the Scorecard protection, puts families at financial risk and may finds that primary care is weak in many states. force them to go without needed care. Nationally, The proportion of adults who reported having a in 2011–12, 16 percent of working-age adults and usual source of care ranged from 63 percent to their dependents resided in households where 89 percent in 2012, falling meaningfully (by at spending on medical care was high relative to least 3 percentage points) in 25 states since 2007. annual income, ranging from a low of 10 percent in Perhaps as a consequence of declining coverage Minnesota and the District of Columbia to a high among adults and increased cost-related barriers of 22 percent in Idaho and Utah (Appendix Exhibit to care, the proportion of older adults who received A4). Nationally, nearly one of five (17%) adults who a complete bundle of recommended preventive needed care reported they could not get it because services—including screenings for certain cancers of cost in 2012, up from 13 percent in 2007—before and annual flu shots—also declined meaningfully widespread impact of the economic recession. No (by at least 2 percentage points) in 30 states between state did better on this indicator in 2012 than in 2006 and 2012 (Appendix Exhibit A6). 2007; cost-related barriers to care in states with the As access deteriorated during the economic highest rates were twice as great as in states with the recession, the share of adults who reported poor lowest rates (Exhibit 12). health-related quality-of-life rose from 24 percent 22 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Exhibit 12. Percent of Adults Who Went Without Care Because of Cost, 2007 vs. 2012 Percent 2012 2007 25 20 15 10 5 0 Wyoming* Alabama** Kansas** Nevada** Georgia** Texas* Mississippi** Hawaii* Massachusetts* North Dakota* Vermont Maine Iowa* South Dakota* Minnesota* Connecticut* District of Columbia* Nebraska* Delaware* Wisconsin** New Hampshire* Rhode Island* Ohio* Illinois Alaska Missouri New York* Washington* Michigan** Utah* New Jersey* Indiana** Colorado* Idaho Oregon** Louisiana Kentucky* North Carolina* West Virginia* Tennessee** Arizona** Arkansas** South Carolina** Florida** Pennsylvania** Maryland Virginia** New Mexico** Oklahoma Montana* California** Note: States are arranged in rank order based on their current data year (2012) value. States with at least a 0.5 standard deviation change (–2 percentage points) between 2007 and 2012 are denoted with (*); states with at least a 1.0 standard deviation change (–4 percentage points) are denoted with (**). Data: 2007 and 2012 Behavioral Risk Factor Surveillance System (BRFSS). Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. in 2007 to 27 percent in 2012, with 40 states Health system performance for children is vari- plus the District of Columbia experiencing an able: some promising gains in recent years, but erosion in health-related quality of life of least also troubling declines. 2 percentage points (Appendix Exhibit A11).22 Performance on the Scorecard’s seven child- Dental health also declined in multiple states: focused indicators varied across states (five of seven the percentage of adults who reported having lost indicators are shown in Exhibit 13). In addition to six or more teeth to gum disease or tooth decay is the aforementioned improvements in immunization up in 10 states, topping out at 23 percent in West rates and coverage for children, several states saw Virginia. With strong associations between tooth meaningful reductions in hospital admissions loss and lower quality of life, chronic disease, among children with asthma. Nationally, the rate emergency department use, and hospitalization, declined by 17 percent, which translates into 10 these negative dental health trends highlight the admissions per 100,000 children, and rates were need for policy initiatives to consider all aspects down in 16 of the 36 states for which these data are of people’s health.23 Meanwhile, adult obesity rose available (Appendix Exhibit A8). nationally and in 25 states, signaling potential Other child-focused indicators paint a more future problems in terms of chronic disease, costs troubling picture. For example, the share of and outcomes. children who received primary care in medical homes dropped from 58 percent in 2007 to 54 percent in 2011–12, with declines in more than half of states. Medical homes are patient-centered www.commonwealthfund.org23 Exhibit 13. State Variation: Child Health Indicators, 2012 Percent Top state All-state median Bottom state 100 90 80 86 81 80 70 60 69 69 69 63 60 50 57 56 40 45 40 40 30 30 20 22 10 0 Children with a medical Children with medical Children with emotional, Children ages 19–35 Children ages 10–17 who home and dental preventive behavioral, or developmen- months who received are overweight or obese care visits tal problems who received all recommended doses (BMI >= 85th percentile) needed mental health care of seven key vaccines TOP STATES 1. Vermont 1. Vermont 1. North Dakota 1. Hawaii 1. Utah 2. Iowa 2. Connecticut 2. Maine 1. New Hampshire 2. Colorado 2. New Hampshire 2. Massachusetts 2. Vermont 3. Mississippi 3. New Jersey 4. Wisconsin 2. New Hampshire 4. West Virginia 4. Connecticut 3. Vermont 5. Utah 5. Dist. of Columbia 5. Two tied 5. Four tied 5. Four tied Data: Children with a medical home and children with preventive and mental health care: 2011–12 National Child Health Survey (NCHS); Children who received recommended vaccines: 2012 National Immunization Survey; Children who are overweight or obese: 2012 Behavioral Risk Factor Surveillance System (BRFSS). Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. care practices that provide easy access to primary Health care spending continued to rise in the and preventive care and help coordinate care and private market, but the Medicare program expe- referrals for specialized care. Of the six states where rienced historic moderation in costs. the uninsured rates among children increased, all Growth in total health care spending among all but one also saw a decline (not necessarily to the Medicare beneficiaries has slowed in recent years, meaningful standard) in the share of children who with 2.9 percent growth per year from 2007 to 2012 received care from a medical home (Appendix compared with 7.8 percent per year from 2002 to Exhibits A4 and A6). 2007.25 This slowdown is also reflected in the state- The proportion of children with emotional, level spending estimates used in this Scorecard, behavioral, or developmental problems who which are restricted to fee-for-service beneficiaries received needed mental health services increased age 65 and older and exclude prescription drug slightly nationally, but performance changed in spending.26 Using this restricted definition of both directions among the states. Fourteen states Medicare spending, the Scorecard finds that per- saw improvements of 4 percentage points or beneficiary spending grew an average of 1.9 percent more between 2007 and 2011–12, while 20 states per year between 2008 and 2012, and declined saw declines of this same magnitude. There was slightly from 2011 to 2012 (Exhibit 14). Still, growth little overall change in the obesity rate among in Medicare spending remained highly variable children ages 10 to 17 between 2007 and 2011–12. across states—ranging from 1.1 percent per year in Meaningful reductions were seen in 18 states, but Alabama and Louisiana to more than 4 percent per rates worsened in 14 others.24 24 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Exhibit 14. Change in Employer-Sponsored Insurance Premiums and Medicare Spending, 2008 to 2012 NATIONAL TREND STATE CHANGE Single-person employer-sponsored insurance premium Less than or equal to 8% growth, 2008 to 2012 Medicare spending per beneficiary 9% to14% growth, 2008 to 2012 15% or higher growth, 2008 to 2012 Cumulative percent change from baseline year 25 Medicare 21 spending per 26 22 3 beneficiary 17 13 9 Single-person - employer-sponsored 2 5 44 5 insurance premium 1 2008 2009 2010 2011 2012 Number of states + D.C. Notes: Medicare spending estimates exclude prescription drug costs and reflect only the age 65+ Medicare fee-for-service population. For measuring trend, Medicare spending and insurance premiums are unadjusted. For of ranking (reported elsewhere in the Scorecard), 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. Data: Medicare spending: Medicare claims via Dec. 2013 CMS Geographic Variation Public Use File; Insurance premiums: 2013 Medical Expenditure Panel Survey (MEPS). Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. year in North and South Dakota.27 (See Appendix to enrollees through higher deductibles and cost- Exhibit A9 for spending estimates by state.) sharing.29 Health care spending for the commercially insured population (as measured by single-person States’ progress was mixed in reducing health health insurance premiums for employer-sponsored care disparities between vulnerable and more advantaged groups coverage) also slowed compared with earlier years Equitable access to high-quality health care but continued to rise more rapidly than Medicare. remains an unfulfilled goal across the nation. Average health insurance premiums for an Despite all states devoting considerable resources employer-sponsored single-person plan28 increased to support their low-income populations through in every state between 2008 and 2012, with annual Medicaid and CHIP programs, disparities in health growth rates ranging from 2 percent per year in and health care within states—as well as geographic Idaho and New Hampshire to nearly 9 percent per disparities across states—remain widespread. (For year in North Dakota and Alaska (Appendix Exhibit an in-depth examination of such disparities, see A9). Nationally, the average was 5.3 percent per Health Care in the Two Americas: Findings from the year—nearly three times the increase in Medicare Scorecard on State Health System Performance for spending per person over the same period (Exhibit Low-Income Populations, 2013.30) 14). State progress toward closing equity gaps (see Slower growth in Medicare spending per person box on next page) varies by indicator. For seven was achieved without a cut in benefits. Employer- indicators of health system equity for which trend sponsored insurance premiums, however, are data were available, at least half of all states improved growing faster and premiums are buying less in recent years (Exhibit 15)—meaning the rate coverage each year, with costs increasingly shifted improved for the state’s most-vulnerable group and www.commonwealthfund.org25 Exhibit 15. Change in Equity Dimension Performance by Indicator Number of States Where Equity for the Disparate Population: a Equity Subdimension and Indicator Improveda No Change Worseneda Race/Ethnicity 0 Uninsured ages 0–64 28 7 16 Adults who went without care because of cost in the past year 12 16 23 At-risk adults who did not visit a doctor for a routine checkup in past 2 years 19 3 28 Adults without a usual source of careb 22 9 20 Children without a medical homeb 25 12 14 Older adults without recommended preventive careb 21 10 15 Mortality amenable to health care 30 6 1 Infant mortality, deaths per 1,000 live births 28 5 15 Adults with poor health-related quality of life 12 17 22 Income Uninsured ages 0–64 25 14 12 Adults who went without care because of cost in the past year 11 30 10 At-risk adults who did not visit a doctor for a routine checkup in past 2 years 33 10 8 Adults without a usual source of careb 33 14 4 Children without a medical homeb 17 15 19 Older adults without recommended preventive careb 14 14 23 Adults with poor health-related quality of life 6 12 33 Notes: Selected indicators only. Trend data generally reflect the five-year period ending in 2011 or 2012—refer to Appendix B for additional detail. (a) Improvement indicates that the equity gap between states’ disparate population and the U.S. average narrowed and that the rate among the states’ disp arate population improved. Worsening indicates that the equity gap between states’ disparate population and the U.S. average widened and that the rate among the st ates' disparate population got worse. (b) Directionality of these indicators is reversed from how reported elsewhere in the report. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. the gap narrowed between that vulnerable group declined—meaning the rate worsened for the most- and the U.S. average. All states closed the equity gap vulnerable group and the gap widened between that and improved care for their most-vulnerable group group and the U.S. average. on at least two indicators, and five states (D.C., Racial and ethnic minorities face significant La., Md., Mass., and Va.) improved on 10 to 12 barriers to care. For example, rates of premature indicators (Appendix Exhibit A14). Unfortunately, death were higher among blacks than whites in all for all equity indicators, there were states that states where mortality data are available for both HOW THE STATE SCORECARD DEFINES EQUITY The Scorecard evaluates states on the equity of their health systems along two dimensions: race and ethnicity (10 indica- tors) and income (nine indicators). Equity indicators are a subset of indicators chosen to represent care across three of four performance domains. For each state, health system performance on each indicator as it pertains to low-income populations (under 200% of the federal poverty level) and racial or ethnic minority groups (black/other race or Hispanic ethnicity) is compared with the national average. The resulting difference in performance is the “equity gap,” which forms the basis of our state rankings for this domain. To assess change over time, we count how often the equity gap narrowed across indicators for each state during the five years of data available for this Scorecard. We consider improvement to have occurred only if the equity gap narrowed and health care for the states’ vulnerable group improved. (See state profiles and supplemental data tables online for state equity rankings and indicators by income and racial or ethnic group for each state.) 26 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Exhibit 16. Mortality Amenable to Health Care by Race, State Variation, 2009–10 Deaths per 100,000 population Black White 200 150 100 50 U.S. average, all races = 86 per 100,000 0 Washington Arkansas Nevada New Jersey Mississippi Georgia Massachusetts North Carolina Pennsylvania Colorado Minnesota New Mexico Connecticut Arizona Florida Nebraska Indiana Texas Missouri Kentucky Wisconsin Alabama Illinois Tennessee Michigan Louisiana Kansas New York Virginia South Carolina Ohio Maryland California District of Columbia Oklahoma Delaware West Virginia Notes: Data for Black population are not available for Alaska, Hawaii, Idaho, Iowa, Maine, Montana, New Hampshire, North Dakota, Oregon, Rhode Island, South Dakota, Utah, Vermont, or Wyoming. States are arranged in rank order based on black mortality. Data: 2004–05 and 2009–10 National Vital Statistics System (NVSS) mortality all-county micro data files. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. races—sometimes more than twice as high (Exhibit Georgia, Indiana, Mississippi, and North Carolina 16). But geography matters, too: in five states (Ark., faced some of widest disparities relative to the Ky., Miss., Okla., W.Va.) premature death rates for national average across all of the indicators assessed whites were higher than the rate for blacks in the in our Equity dimension. best-performing state (Mass.). Although the racial Disparities by income were equally troubling. disparity narrowed overall between 2004–05 and With regard to the share of adults with poor health- 2009–10 on this indicator, the gap in death rates related quality-of-life, the equity gap widened and between whites and blacks remained wider in states the experience of low-income individuals worsened with the highest overall death rates than in states in more than half of states. In four states (Ala., La., with lower overall death rates (Appendix Exhibit Ore., and W.Va.), half of all low-income adults A12). Also, in three-quarters of states for which reported poor health-related quality-of-life in 2012, data are available, the infant mortality rate among nearly twice the national average. (See supplemental children born to black parents was twice the rate of data tables for indicators by income and racial or children born to white parents. ethnic group for each state.) Disparities also persist for Hispanics. In 27 states and the District of Columbia, Hispanics were Widespread geographic variation in health system twice as likely to go without care because of cost performance illustrates what may be achieved and highlights opportunities for improvement. compared with non-Hispanic whites. In Maryland Minnesota, Massachusetts, New Hampshire, and the District of Columbia, Hispanics were Vermont, and Hawaii lead the nation across most more than three times as likely to face cost-related dimensions of care currently and in prior time barriers. Racial and ethnic minorities in Arkansas, www.commonwealthfund.org27 periods (Exhibits 3 and 4). Their consistently • More than 35 million adults and children high performance may be credited in part to would gain health insurance, helping to reduce their wherewithal to invest in health and social cost barriers to receiving needed care. initiatives and their willingness to address health • More than 13 million fewer individuals would system change. In contrast, consistently lagging be burdened by high medical spending relative performance among states at the bottom of the to their income, and nearly 19 million fewer rankings—concentrated among those in the South adults would forgo needed care because of cost. and Southeast—reflects high rates of uninsured, • About 10 million additional older adults would deteriorating affordability, and inconsistent quality receive key recommended preventive care and patient outcomes. Lagging states may benefit services such as cancer screenings and flu shots. from the examples set by other states, particularly • More than a million fewer Medicare beneficiaries neighbors with similar socioeconomic challenges, would receive an unsafe prescription drug. that are doing better on particular areas of performance and by advancing policies that help • Medicare beneficiaries would have nearly ensure affordable coverage and quality care. 1.5 million fewer emergency room visits for State variation narrowed for 11 indicators nonemergent and/or primary-care treatable for which lagging states improved faster than conditions. leading states (Exhibit 2). Most of these were • There would be approximately 84,000 fewer indicators on which there was also widespread state premature deaths before age 75 for conditions improvement—illustrating that states can close the that can be detected early and effectively treated performance gap, even as the top states improve. At with good follow-up care. the same time, variation widened for 16 indicators, • Nearly 10 million fewer adults (ages 18–64) as leading states pulled ahead or lagging states would lose six or more teeth to decay, infection, worsened, or both. Even leading states did not or gum disease. perform consistently well or consistently improve (See Appendix Exhibit A2 for additional across all performance indicators. examples of the potential gains that might be Opportunities for improvement abound. Only expected if all states achieved benchmark levels.) two states (N.H. and Vt.) ranked in the top quartile These are ambitious—even aspirational— across all five dimensions of care; none ranked targets. But by aiming high, policymakers and near the top on all 42 indicators. All states, even delivery system leaders are more likely to succeed in top-performers, had at least one indicator that raising the bar. ranked in the bottom quartile—well below what is achievable. In fact, all 10 top-ranked states had at least five indicators in the bottom half of the state distribution (Appendix Exhibit A1). Capitalizing on opportunities for improvement would expand access to care, save lives, and improve care experiences for patients. If all states achieved the benchmarks set by top-performing states, nationally we might expect: 28 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 IMPLICATIONS Policymakers in several top-performing states Health system performance as measured by the have articulated a clear vision of what health care State Scorecard in large part reflects a confluence should look like and are working hard to realize of national policy and state and local initiatives. that vision. Vermont, ranked second overall in 2014 States, in particular, influence health system and consistently near the top in previous years, has performance in many ways: by purchasing care for a history of enacting policies that promote better low-income populations and their own employees; performance. A national leader in guaranteeing by regulating providers and establishing rules access to care and investing in primary care, the state that guide health care and insurance markets; by most recently established a “blueprint for health” setting statewide strategy for health information that emphasizes disease prevention, chronic disease technology and exchange; by supporting public management, and care coordination through a health; and, increasingly, by acting as conveners community-based medical home model.32 and collaborators for improvement initiatives Looking across states, a high rate of uninsured with other health care stakeholders. The Scorecard adults is often associated with low rates of findings of isolated improvement but, just as often, preventive care and with poor health outcomes. also stagnation or decline underscore the need for Increased access has been shown to support concerted action by all states. broader improvements in quality of care and health MORE KEY FINDINGS ACCESS • Performance stagnated nationally on two access measures with mixed results at the state level: at-risk adults (i.e., those 50 and older with a chronic condition or with “fair” or “poor” self-reported health status) who did not see a doctor for a routine checkup in two years (14 states improved while 11 worsened), and adults without a dental visit in the past year (seven states improved while 18 worsened) (Appendix Exhibit A4). PREVENTION AND TREATMENT • There were stark gaps across states in the proportion of children who received routine preventive medical and dental visits in the previous year, as measured in 2011–2012. Rates ranged from a high of 81 percent in Vermont to a low of 56 percent in Nevada. • From 2007 to 2011, nearly all states saw meaningful improvement on an indicator that tracks patients’ ratings of their hospital experience, including whether hospital staff always managed their pain well, explained medicines, and responded when the call button was pushed. There were similar gains among 48 states in the proportion of hospitalized patients given information about what to do during their recovery at home. AVOIDABLE HOSPITAL USE AND COST • The proportion of short-stay nursing home residents with a readmission to the hospital and the share of long-stay residents with a hospital admission were unchanged between 2006 and 2010, with two- to fourfold variation persisting across states (Appendix Exhibit A8). • Twofold variation across states in rates of potentially avoidable visits to hospital emergency departments highlights the oppor- tunity for improving access to primary care. Rates ranged from less than 150 avoidable visits per 1,000 Medicare beneficiaries in Hawaii, Utah, and Nebraska to at least 230 per 1,000 in West Virginia, Maine, and the District of Columbia. HEALTHY LIVES • Suicide deaths were up substantially in 18 states, while no states saw a meaningful reduction, a concerning reminder that men- tal health services may be difficult to access or that they are not being delivered adequately.31 www.commonwealthfund.org29 status.33 The implications of these findings may play and Arkansas, which are currently ranked in the out across the nation as states choose whether and Scorecard’s bottom quartile but are expanding how to move forward with the Affordable Care Act’s Medicaid and prepared to take advantage of the coverage expansions. To date, 16 of the 26 bottom- new federal resources and delivery system reforms, performing states (those in the third and fourth could see greater improvements in coming years performance quartiles) have so far chosen not to relative to other states at the bottom that are not expand Medicaid eligibility (Exhibit 3). States that fully participating in the ACA’s reforms. (See reject expansion will forgo an infusion of federal sidebar to learn about Arkansas’s approach.) Local dollars to support low-income populations and health system leaders can also make a difference by traditionally underserved and rural areas, and they choosing to participate in Medicare and private- will miss important opportunities to lower the costs sector-based accountable care and value-based of uncompensated care for their hospitals.34 payment initiatives, which are beginning to yield It will be important to continue tracking promising results.36 health system performance as health reforms are The Scorecard’s findings remind us that where implemented, paying close attention to states that are you live matters. The sobering truth is that residents expanding Medicaid and participating in other of certain states continue to realize greater benefits reforms, such as health homes and accountable from their health care systems than those in other care.35 In particular, states like Kentucky, Nevada, states do. But it doesn’t have to be this way. By ARKANSAS: ON THE MOVE In this and previous State Scorecards, Arkansas ranked in the bottom quartile, lagging other states on indicators of health system per- formance. But Arkansas is quickly developing another reputation, as a state at the forefront of the effort to achieve the “triple aim” of better care, better health, and lower costs. In 2011, spiraling health care costs and a gaping shortfall in the state Medicaid budget prompted Arkansas Medicaid and the state’s two largest private insurers to launch the Arkansas Health Care Payment Improvement Initiative. Its goal is to move Arkansas’s health system from a payment model that rewards volume to one that rewards high-quality, efficient care. The initiative pays providers for “episodes” that require coordinated care for a given length of time. So far, these episodes have included upper respiratory infections, pregnancy, and joint replacements, with more set to roll out this year. Providers must meet quality standards, and depending on their average costs per episode, may share in the savings or be on the hook for some of the excess costs. The model also includes trans- forming primary care practices into patient-centered medical homes that provide patients with extended office hours, recommended preventive services, care coordination, and management of chronic conditions and creating health homes for high-need, high-cost patients who require a more intensive range of services. The state is working to maximize the number of payers involved in the initiative. Two of the largest self-insured employers have signed on. In addition, insurance carriers participating in Arkansas’s customized approach to expanding Medicaid under the Affordable Care Act also must participate. This approach, known as the “private option,” uses federal dollars earmarked for Medicaid expansion to purchase private insurance plans in the state’s health insurance marketplace for eligible nonelderly adults with incomes below 138 i ii percent of the federal poverty level. As of February 2014, about 100,000 people had gained coverage through the private option. As states test various avenues to expanding coverage and controlling health care costs, Arkansas is one to watch to see whether its approach linking coverage and delivery system reforms measurably improves health system performance for its residents in coming years. i T. Garber and S. R. Collins, “The Affordable Care Act’s Medicaid Expansion: Alternative State Approaches,” The Commonwealth Fund Blog, March 28, 2014. ii Arkansas Department of Human Services, Media Release, “Private Option Enrollments Continue to Increase in Every County, More Than Half Under 40,” Feb. 10, 2014. 30 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 acknowledging that access to care is the foundation health and leading by example through value-based of a high-performing health system and by focusing purchasing in state Medicaid and employee health on the needs of low-income and other vulnerable benefit programs. populations, all states can safeguard and promote Only by aiming high can the U.S. reach its the health of their residents.37 And all states can potential as a nation where geography is not strive to enhance patient care experiences, improve destiny, and where everyone, everywhere, has the health outcomes, and lower health care spending, opportunity to live a long and healthy life. such as by enacting policies that promote public SCORECARD METHODOLOGY The Commonwealth Fund’s Scorecard on State Health System Performance, 2014, evaluates 42 key indicators grouped into four dimensions (Exhibit 2): ◊ 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-related barriers to receiving care. ◊ Prevention and Treatment (16 indicators): includes measures of receiving preventive care and the quality of care in ambulatory, hospital, and long-term care and postacute settings. ◊ Potentially Avoidable Hospital Use and Cost (nine indicators, with one indicator, hospital admissions for ambulatory care–sensitive conditions, reported separately for two distinct age groups): includes indicators of hospital use that might have been reduced with timely and effective care and follow-up care, as well as esti- mates of per-person spending among Medicare beneficiaries and the cost of employer-sponsored insurance. ◊ Healthy Lives (11 indicators): includes indicators that measure premature death and health risk behaviors. In addition, the Equity dimension includes differences in performance associated with patients’ income level (nine indi- cators) or race or ethnicity (10 indicators) that span the four other dimensions of performance. The following principles guided the development of the Scorecard: 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 the 2009 Scorecard, several indicators have been dropped either because all states improved to the point where no mean- ingful variations existed or the data to construct the measures were no longer available. Several new indicators have been added, including measures of premature death, out-of-pocket spending on medical care relative to income, and potentially avoidable emergency department use. Measuring Change over Time. We were able to construct a time series for 34 of 42 indicators. There was generally five years between a historical and current year data observation, though the starting and ending points, as well as total length of time, varied somewhat between indicators. We considered a change in an indicator’s value between the his- torical and 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 the two time points—a common approach in social science research.38 Data Sources. Indicators draw from publicly available data sources, including government-sponsored surveys, registries, publicly reported quality indicators, vital statistics, mortality data, and administrative databases. The most current data available were used in this report. Appendix B provides detail on the data sources and time frames. Scoring and Ranking Methodology. The scoring method follows previous state scorecards. States are first ranked from best to worst on each of the 42 performance indicators. We averaged rankings for indicators within 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 weights indicators equally. Ranking in the earlier period (i.e., revised 2009 data) was based on 34 of 42 indicators; if historical data were not available for a particular indicator, 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. www.commonwealthfund.org31 NOTES N. L. Rucker, “Medicare Part D’s Medication Therapy 9 Management: Shifting from Neutral to Drive,” Insight on the 1 National health expenditure data (Table 1): http://www.cms.gov/ Issues, No. 64 (Washington, D.C.: AARP Public Policy Institute, Research-Statistics-Data-and-Systems/Statistics-Trends-and- June 2012), http://www.aarp.org/content/dam/aarp/research/ Reports/NationalHealthExpendData/Downloads/tables.pdf; public_policy_institute/health/medicare-part-d-shifting-from- State health expenditure data: http://www.cms.gov/Research- neutral-to-drive-insight-AARP-ppi-health.pdf; D. C. Radley, Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ M. R. Wasserman, L. E. Olsho et al., “Reduction in Medication NationalHealthExpendData/Downloads/res-tables.pdf. Errors in Hospitals Due to Adoption of Computerized Provider Order Entry Systems,” Journal of the American Medical 2 A. H. Pande, D. Ross-Degnan, A. M. Zaslavsky et al., “Effects Informatics Association, May 1, 2013 20(3):470–76; and C. J. of Healthcare Reforms on Coverage, Access, and Disparities: Hsiao, E. Hing, T. C. Socey et al., “Electronic Health Record Quasi-Experimental Analysis of Evidence from Massachusetts,” Systems and Intent to Apply for Meaningful Use Incentives American Journal of Preventive Medicine, July 2011 41(1):1–8. Among Office-Based Physician Practices: United States, 2001– 3 P. J. van der Wees, A. M. Zaslavsky, and J. Z. Ayanian, 2011,” NCHS Data Brief, No. 79 (Hyattsville, Md.: National “Improvements in Health Status After Massachusetts Health Care Center for Health Statistics, Nov. 2011), http://www.cdc.gov/ Reform,” Milbank Quarterly, Dec. 2013 91(4):663–89. nchs/data/databriefs/db79.htm. 4 Kaiser Commission on Medicaid and the Uninsured, “State 10 Data from 2004 as reported in J. C. Cantor, C. Schoen, D. Children’s Health Insurance Program (CHIP): Reauthorization Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results History,” Publication #7743-02 (Washington, D.C.: Henry from a State Scorecard on Health System Performance (New J. Kaiser Family Foundation, revised Feb. 2009), http:// York: The Commonwealth Fund, June 2007) and reproduced kaiserfamilyfoundation.files.wordpress.com/2013/01/7743-02. from 2004 Hospital Compare data. Data from 2012 are from pdf. Hospital Compare (analysis by IPRO). Hospital process quality measures for heart attack, heart failure, pneumonia, and surgical 5 Centers for Disease Control and Prevention, “VFC Program: patients receiving surgery have been reported in all previous Vaccines for Uninsured Children” (Atlanta: CDC), http://www. Commonwealth Fund scorecards. Given the progress that has cdc.gov/features/vfcprogram/. been made in recent years and the narrow distribution between 6 C. L. Black, D. Yankey, and M. Kolasa, “National, State, and states, these measures have been retired from our report. Local Area Vaccination Coverage Among Children Aged 19–35 11 Centers for Disease Control and Prevention, National and State Months—United States, 2012,” Morbidity and Mortality Weekly Healthcare Associated Infections: Progress Report (Atlanta: CDC, Report, Sept. 13, 2013 62(36):733–40. March 2014). 7 Recommended vaccines are the 4:3:1:3:3:1:4 series, which 12 C. Marks, S. Loehrer, and D. McCarthy, Hospital Readmissions: includes ≥4 doses of DTaP/DT/DTP, ≥3 doses of poliovirus Measuring for Improvement, Accountability, and Patients (New vaccine, ≥1 doses of measles-containing vaccine, full series of York and Cambridge, Mass.: The Commonwealth Fund and the Hib (3 or 4 doses, depending on product type), ≥3 doses of Institute for Healthcare Improvement, Sept. 2013). HepB, ≥1 dose of varicella vaccine, and ≥4 doses of PCV. 13 Centers for Medicare and Medicaid Services, “Readmissions 8 Certain medications that are commonly taken by younger Reduction Program,” http://www.cms.gov/Medicare/Medicare- patients without incident can put those age 65 and older Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions- at increased risk for experiencing severe side effects and Reduction-Program.html. complications, regardless of the dose, frequency, or how healthy the patient is. These adverse drug events can include 14 “New Data Shows Affordable Care Act Reforms Are Leading to confusion, sedation, immobility, falls, and fractures. The National Lower Hospital Readmission Rates for Medicare Beneficiaries,” Committee for Quality Assurance (NCQA) has identified more The CMS Blog, Dec. 6, 2013, http://blog.cms.gov/2013/12/06/ than 100 “high-risk medications in the elderly” that should be new-data-shows-affordable-care-act-reforms-are-leading-to- avoided by those 65 and older. The drugs fall into numerous lower-hospital-readmission-rates-for-medicare-beneficiaries/. categories, ranging from antianxiety drugs and antihistamines 15 J. Brock, J. Mitchell, K. Irby et al., “Association Between Quality to narcotics and muscle relaxants. Safer alternatives may Improvement for Care Transitions in Communities and be available, but as the Scorecard finding makes clear, these Rehospitalizations Among Medicare Beneficiaries,” Journal of the potentially harmful medications are still frequently prescribed American Medical Association, Jan. 23, 2013 309(4):381–91. to the elderly. To view the NCQA list of high-risk medications, visit http://www.ncqa.org/Portals/0/newsroom/SOHC/Drugs_ 16 R. Kaestner, C. Long, and G. C. Alexander, Effects of Prescription Avoided_Elderly.pdf. Drug Insurance on Hospitalization and Mortality: Evidence from Medicare Part D, NBER Working Paper No. 19948 (Cambridge, Mass.: National Bureau of Economic Research, Feb. 2014), http:// www.nber.org/papers/w19948. 32 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 17 The age-adjusted percentage of adults with hypertension whose 25 Centers for Medicare and Medicaid Services, National Health blood pressure was controlled increased from 48.4 percent in Expenditure Data. Spending estimates cited throughout this 2007–2008 to 53.3 percent in 2009–2010; see: S. S. Yoon, V. report come from Tables 1 & 21 at http://cms.gov/Research- Burt, T. Louis et al., “Hypertension Among Adults in the United Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ States, 2009–2010,” NCHS Data Brief No. 107 (Hyattsville, Md.: NationalHealthExpendData/Downloads/tables.pdf (last accessed National Center for Health Statistics, Oct. 2012), http://www.cdc. March 10, 2014). gov/nchs/data/databriefs/db107.htm. 26 Medicare spending estimates used in the Scorecard for state 18 E. Nolte and C. M. McKee, “In Amenable Mortality—Deaths rankings are restricted to beneficiaries age 65 and older and Avoidable Through Health Care—Progress in the U.S. Lags exclude prescription drug spending—these data come from That of Three European Countries,” Health Affairs Web First, CMS’ Geographic Variation Public Use File (refer to Appendix B published online Aug. 29, 2012. for more detail on data source). Despite being limited relative to other CMS-based estimates of total spending (refer to endnote 19 Authors’ analysis of Current Population Survey data, as prepared 26), this source is favored for our scorecards because of their using the online CPS Table Creator tool. Last Accessed Feb. 10, availability at the state and substate levels. 2014. 27 When comparing states, spending estimates were adjusted for 20 M. E. Martinez and R. A. Cohen, “Health Insurance Coverage: state wage differences and additional Medicare payments for Early Release of Estimates from the National Health Interview graduate medical education and for treating low-income patients Survey, January–June 2013” (Hyattsville, Md.: National Center were excluded. for Health Statistics. Dec. 2013), http://www.cdc.gov/nchs/data/ nhis/earlyrelease/insur201312.pdf; J. Leavy. “U.S. Uninsured Rate 28 Wage adjusted using the CMS hospital wage index to account for Continues to Fall: Uninsured Rate Drops Most Among Lower- across-state variation in workers wages. Income and Black Americans,” Gallup, Inc., March 10 2014), 29 C. Schoen, J. A. Lippa, S. R. Collins, and D. C. Radley, State http://www.gallup.com/poll/167798/uninsured-rate-continues- Trends in Premiums and Deductibles, 2003–2011: Eroding fall.aspx. Protection and Rising Costs Underscore Need for Action (New 21 B. Starfield, Primary Care: Balancing Health Needs, Services and York: The Commonwealth Fund, Dec. 2012). Technology (New York: Oxford University Press, 1998). 30 C. Schoen, D. C. Radley, P. Riley, J. A. Lippa, J. Berenson, C. 22 M. Seid, J. W. Varni, L. Cummings et al., “The Impact of Realized Dermody, and A. Shih, Health Care in the Two Americas: Findings Access to Care on Health-Related Quality of Life: A Two-Year from the Scorecard on State Health System Performance for Low- Prospective Cohort Study of Children in the California State Income Populations, 2013 (New York: The Commonwealth Fund, Children’s Health Insurance Program,” Journal of Pediatrics, Sept. Sept. 2013). 2006 149(3):354–61. 31 P. S. Wang, O. Demler, and R. C. Kessler, “Adequacy of Treatment 23 T. Wall and K. Nasseh, “Dental-Related Emergency Department for Serious Mental Illness in the United States,” American Visits on the Increase in the United States,” ADA Health Policy Journal of Public Health, Jan. 2002 92(1):92–98; and “Mental Resources Center Research Brief (Chicago: American Dental Health Care: Adequacy of Treatment for Adults,” available from Association, April 2013); M. C. Hollister and J. A. Weintraub, Commonwealth Fund Performance Snapshots at http://www. “The Association of Oral Status with Systemic Health, Quality of commonwealthfund.org/Content/Performance-Snapshots/ Life, and Economic Productivity,” Journal of Dental Education, Mental-and-Behavioral-Health-Care/Mental-Health-Care-- Dec. 1993 57(12):901–12; P. E. Peterson, “World Health Adequacy-of-Treatment-for-Adults.aspx. Organization Global Policy for Improvement of Oral Health— 32 C. Bielaszka-DuVernay, “Vermont’s Blueprint for Medical World Health Assembly 2007,” International Dental Journal, Homes, Community Health Teams, and Better Health at Lower June 2008 58(3):115–21; and S. A. Fisher-Owens, J. C. Barker, Cost,” Health Affairs, March 2011 30(3):383–86. S. Adams et al., “Giving Policy Some Teeth: Routes to Reducing Disparities in Oral Health,” Health Affairs, March/April 2008 33 Van der Wees, Zaslavsky, and Ayanian, “Improvements in Health 27(2):404–12. Status,” 2013. 24 Childhood obesity has been identified as a major threat to 34 D. Blumenthal, “Two Americas,” The Commonwealth Fund public health in the United States. Not only do obese children Blog, Aug. 14, 2013; and S. Glied and S. Ma, How States Stand to face adverse health effects in the near term, they are likely to be Gain or Lose Federal Funds by Opting In or Out of the Medicaid obese as adults, placing them at risk for heart disease, diabetes, Expansion (New York: The Commonwealth Fund, Dec. 2013). cancer, and joint problems later in life—with implications 35 S. Silow Carroll, J. N. Edwards, and D. Rodin, Aligning Incentives for future health spending and population health outcomes. in Medicaid: How Colorado, Minnesota, and Vermont Are See: C. L. Ogden, M. D. Carroll, B. K. Kit et al., “Prevalence of Reforming Care Delivery and Payment to Improve Health and Obesity and Trends in Body Mass Index Among U.S. Children Lower Costs (New York: The Commonwealth Fund, March 2013). and Adolescents, 1999–2010,” Journal of the American Medical Association, Feb. 1, 2012 307(5):483–90; D. S. Freedman, M. Zuguo, S. R. Srinivasan et al., “Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study,” Journal of Pediatrics, Jan. 2007 150(1):12–17; and S. S. Guo and W. C. Chumlea, “Tracking of Body Mass Index in Children in Relation to Overweight in Adulthood,” American Journal of Clinical Nutrition, 1999 70(1):S145–S148. www.commonwealthfund.org33 36 D. Muhlestein, “Accountable Care Growth in 2014: A Look Ahead,” Health Affairs Blog, Jan. 29, 2014, http://healthaffairs. org/blog/2014/01/29/accountable-care-growth-in-2014-a- look-ahead/; Centers for Medicare and Medicaid Services, “Medicare’s Delivery System Reform Initiatives Achieve Significant Savings and Quality Improvements—Off to a Strong Start,” Press Release, Jan. 30, 2014, http://www.hhs.gov/news/ press/2014pres/01/20140130a.html; and P. Markovich, “A Global Budget Pilot Project Among Provider Partners and Blue Shield of California Led to Savings in First Two Years,” Health Affairs, Sept. 2012 31(9):1969–76. 37 Pande, Ross-Degnan, Zaslavsky et al., “Effects of Healthcare Reforms,” 2011; and M. V. Pauly and J. A. Pagan, “Spillovers and Vulnerability: The Case of Community Uninsurance,” Health Affairs, Sept./Oct. 2007, 26(5):1304–14. 38 B. Middel and E. van Sonderen, “Statistical Significant Change Versus Relevant or Important Change in (Quasi) Experimental Design: Some Conceptual and Methodological Problems in Estimating Magnitude of Intervention-Related Change in Health Services Research,” International Journal of Integrated Care, published online Dec. 17, 2002. 34 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix Exhibit A1. 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 34) improved worsened change 46 Alabama 41 2 2 9 8 22 13 33 7 16 –9 31 Alaska 40 5 7 15 8 10 7 31 11 7 4 36 Arizona 42 1 9 10 13 10 5 34 13 7 6 50 Arkansas 42 0 2 2 14 24 18 34 12 13 –1 26 California 42 5 14 10 10 8 2 34 15 7 8 12 Colorado 42 9 19 13 8 2 0 34 16 6 10 6 Connecticut 42 11 24 11 5 2 0 34 11 10 1 10 Delaware 41 7 15 14 9 3 2 33 10 7 3 21 District of Columbia 39 12 14 8 5 12 9 31 10 7 3 41 Florida 42 2 6 8 16 12 9 34 13 10 3 45 Georgia 42 1 3 6 18 15 3 34 13 12 1 5 Hawaii 40 17 25 6 5 4 3 32 9 8 1 31 Idaho 41 10 16 8 6 11 5 33 10 9 1 26 Illinois 42 0 6 13 17 6 3 33 10 6 4 43 Indiana 42 0 0 11 21 10 3 34 7 13 –6 10 Iowa 42 6 14 22 5 1 1 34 7 7 0 23 Kansas 42 2 5 22 13 2 0 34 10 8 2 42 Kentucky 42 1 4 5 15 18 9 34 12 9 3 48 Louisiana 42 3 5 3 8 26 23 33 14 11 3 7 Maine 42 11 23 9 8 2 1 33 10 6 4 17 Maryland 42 8 11 15 12 4 3 34 14 4 10 2 Massachusetts 42 20 28 6 6 2 0 34 12 5 7 26 Michigan 42 2 7 16 11 8 2 34 10 12 –2 1 Minnesota 42 18 32 5 2 3 2 34 10 10 0 51 Mississippi 41 4 4 2 4 31 25 33 11 10 1 34 Missouri 42 0 2 13 19 8 1 34 11 11 0 29 Montana 42 4 13 10 10 9 4 33 10 11 –1 17 Nebraska 42 7 17 16 7 2 1 34 12 5 7 46 Nevada 42 2 4 9 11 18 11 34 11 12 –1 2 New Hampshire 41 15 24 11 4 2 1 33 15 6 9 15 New Jersey 42 5 18 10 5 9 5 34 13 9 4 36 New Mexico 41 2 7 11 10 13 9 33 11 9 2 19 New York 42 4 12 14 8 8 6 34 16 7 9 36 North Carolina 42 1 4 13 16 9 2 34 15 7 8 14 North Dakota 41 8 13 15 7 6 2 33 9 11 –2 31 Ohio 42 0 0 17 15 10 3 34 12 11 1 49 Oklahoma 42 0 2 6 9 25 9 33 12 8 4 24 Oregon 42 9 11 15 8 8 3 34 12 9 3 22 Pennsylvania 42 3 11 12 14 5 1 33 11 9 2 9 Rhode Island 42 7 18 16 6 2 1 34 9 14 –5 36 South Carolina 42 2 6 7 16 13 4 34 13 13 0 12 South Dakota 42 8 17 15 7 3 1 34 11 9 2 40 Tennessee 42 0 2 10 14 16 8 34 12 10 2 44 Texas 42 1 4 8 15 15 10 34 13 7 6 19 Utah 42 14 21 4 9 8 5 34 9 11 –2 2 Vermont 42 21 29 3 6 4 2 34 12 6 6 24 Virginia 42 0 6 19 15 2 1 34 12 8 4 15 Washington 42 4 14 15 7 6 2 34 9 7 2 34 West Virginia 42 2 6 3 17 16 13 34 10 13 –3 7 Wisconsin 42 9 18 15 7 2 0 34 11 7 4 29 Wyoming 42 4 13 7 13 9 5 33 10 9 1 Notes: Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. In Appendix Exhibit A8, hospital admissions for ambulatory–care sensitive conditions among Medicare beneficiaries are displayed separately for two age ranges, but counted as a single indicator in tallies of indicators and improvement. In instances when the state rates for the two age ranges rank in different quartiles, the higher (better) rank is used to determine state quartile ranking on this indicator. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org35 Appendix Exhibit A2. 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: more adults (ages 18–64) would be covered by health insurance (public or private), and therefore Insured Adults 30,229,859 would be more likely to receive health care when needed. more children (ages 0–17) would be covered by health insurance (public or private), and therefore Insured Children 5,486,872 would be more likely to receive health care when needed. High Out-of-Pocket Medical Spending 13,197,478 fewer individuals would be burdened by high out-of-pocket spending on medical care. Went Without Care Because of Cost 18,777,552 fewer adults (age 18 and older) would go without needed health care because of cost. more adults (age 18 and older) would have a usual source of care to help ensure that care is coordinated Adult Usual Source of Care 25,819,134 and accessible when needed. more adults (age 50 and older) would receive recommended preventive care, such as colon cancer Older Adult Preventive Care 10,184,954 screenings, mammograms, pap smears, and flu shots at appropriate ages. more children (ages 0–17) would have a medical home to help ensure that care is coordinated and Children with a Medical Home 11,116,179 accessible when needed. Children with Preventive Medical and Dental Visits 9,634,022 more children (ages 0–17) would receive annual preventive medical and dental care visits each year. Medicare Received a High-Risk Drug 1,052,042 fewer Medicare beneficiaries would receive an inappropriately prescribed medication. Preventable Hospital Admissions Among Children 77,072 fewer children ages 2 to 17 would be hospitalized for asthma exacerbations. Hospital Readmissions 191,527 fewer hospital readmissions would occur among Medicare beneficiaries (age 65 and older). Hospitalizations of Nursing Home Residents 118,521 fewer long-stay nursing home residents would be hospitalized. Potentially Avoidable Emergency fewer emergency department visits for nonemergent or primary care–treatable conditions would occur 1,488,131 Department Visits among Medicare beneficiaries. fewer premature deaths (before age 75) might occur from causes that are potentially treatable or Mortality Amenable to Health Care 84,777 preventable with timely and appropriate health care. Breast Cancer Deaths 11,509 fewer women might lose their lives fighting breast cancer. Colon Cancer Deaths 11,735 fewer individuals might die from colon cancer. Suicides 16,059 fewer individuals might take their own lives. Infant Mortality 7,435 more infants might live to see their first birthday. Adults Who Smoke 21,124,746 fewer adults would smoke, reducing their risk of lung and heart disease. fewer adults would be obese, with body weights that increase their risk for disease and Adults Who Are Obese 13,524,885 long-term complications. fewer children (ages 10–17) would be overweight or obese, thus reducing the potential for poor health Children Who Are Overweight or Obese 3,022,371 as they transition into adulthood. Adults with Tooth Loss 9,660,632 fewer adults (ages 18–64) would have lost six or more teeth to decay, infection, or gum disease. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 36 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix Exhibit A3. Access & Affordability: Dimension and Indicator Ranking s ar ar o e Performance Quartile pa re tw tin d ye ye d ng - re t e ca di f re isi st o u -o Top Quartile st su su th ut lv en u t pa r in e ta in in h o ta sp o un Second Quartile un al h ar en th u st it ic h i g in tho co t w 18 ye a d 64 Third Quartile 0– of n sit wi ed h – st t e we m it 19 pa ou es vi ts e t ls w Bottom Quartile es ag or ul e th us o ca w h ct ad ua ag th wi n re po vid sk ts ts ts ild ck ul ul ul -ri di RANK Ad Ad Ad Ch do be At In in 1 Massachusetts 1 1 1 1 1 1 2 Connecticut 1 1 1 1 1 1 3 Minnesota 1 2 1 1 2 1 4 Vermont 1 1 1 1 2 1 5 District of Columbia 1 1 1 1 1 3 5 New Hampshire 2 2 1 1 1 1 7 Delaware 1 2 1 1 1 1 7 Wisconsin 1 1 1 2 1 1 9 Iowa 1 1 1 2 2 1 9 Maine 1 1 1 2 1 1 9 North Dakota 1 1 1 1 2 2 9 Rhode Island 2 2 1 1 1 1 13 Maryland 2 3 1 1 1 1 14 Hawaii 1 1 1 2 3 2 14 Pennsylvania 1 2 1 1 2 1 14 Virginia 2 1 2 1 2 1 17 New York 2 1 2 2 1 2 17 South Dakota 2 2 1 2 3 1 19 Michigan 2 1 2 2 2 2 20 New Jersey 3 2 2 2 1 2 21 Kansas 2 2 2 3 2 1 22 Ohio 2 2 2 3 2 2 23 Nebraska 2 3 1 2 4 2 24 Illinois 3 2 2 3 3 2 25 Washington 3 2 2 3 4 2 26 Indiana 2 2 3 3 3 2 27 Missouri 2 4 2 2 3 2 28 Tennessee 2 2 3 4 1 3 29 Kentucky 3 2 3 3 2 3 29 West Virginia 3 3 3 3 1 4 31 Alaska 3 4 2 2 4 2 31 North Carolina 4 3 3 4 2 2 33 Alabama 2 2 4 4 2 4 33 Colorado 3 3 3 3 4 3 33 Oregon 3 2 3 4 4 2 36 Wyoming 3 3 2 4 4 2 37 California 4 4 3 2 3 3 37 Oklahoma 4 2 3 2 4 4 39 Georgia 4 4 4 3 2 3 39 Louisiana 4 3 3 4 1 4 39 Utah 3 3 2 4 4 3 42 Arizona 3 4 4 3 3 3 42 Idaho 3 4 3 4 4 1 44 Montana 4 4 2 4 4 3 44 South Carolina 3 4 4 3 3 4 46 Florida 4 4 4 3 3 4 46 Mississippi 3 3 4 4 3 4 48 Nevada 4 4 3 3 3 4 49 Arkansas 4 3 4 4 3 4 50 Texas 4 4 4 3 4 4 51 New Mexico 4 4 3 4 4 4 Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org37 Appendix Exhibit A4. Access & Affordability: Dimension Ranking and Indicator Rates Individuals with high At-risk adults Adults who went out-of-pocket without a routine Adults ages 19–64 Children ages 0–18 without care because medical doctor visit in Adults without a dental uninsured uninsured of cost in the past year spending past two years visit in the past year 2007–08 2011–12 2007–08 2011–12 2007 2012 2011–12 2007 2012 2006 2012 United States 19% 21% 10% 10% 13% 17% ** 16% 14% 14% 15% 15% Alabama 16 19 * 6 8 * 15 20 ** 19 11 13 * 15 18 ** Alaska 23 23 13 14 14 14 15 21 19 * 16 14 * Arizona 23 23 15 14 13 20 ** 16 15 17 * 16 17 Arkansas 24 26 8 9 16 21 ** 20 20 17 * 16 19 ** California 24 25 11 11 13 17 ** 15 16 16 16 16 Colorado 19 20 13 9 ** 13 16 * 17 20 18 * 13 16 ** Connecticut 12 11 6 5 9 12 * 12 11 10 10 11 Delaware 14 14 8 8 11 13 * 13 7 6 10 12 * District of Columbia 12 11 6 4 * 10 12 * 10 9 7 * 16 16 Florida 25 29 * 18 14 ** 15 21 ** 17 10 15 ** 15 18 ** Georgia 22 26 * 11 12 16 20 ** 17 14 14 13 16 ** Hawaii 10 11 5 4 6 9 * 15 15 15 14 15 Idaho 20 23 * 10 11 17 18 22 21 23 * 15 13 * Illinois 17 20 * 7 7 13 14 16 16 15 16 15 Indiana 16 18 5 8 * 12 16 ** 16 15 17 * 13 15 * Iowa 12 14 5 6 8 11 * 14 13 13 12 12 Kansas 16 19 * 9 8 11 15 ** 16 14 12 * 13 13 Kentucky 20 21 9 8 16 19 * 17 13 14 18 16 * Louisiana 26 28 12 10 * 17 18 18 8 11 * 18 20 * Maine 13 14 5 5 10 11 15 12 11 12 13 Maryland 16 17 8 9 11 11 12 12 8 ** 13 13 Massachusetts 7 5 3 3 7 9 * 11 8 6 * 10 11 Michigan 16 17 5 5 11 15 ** 14 13 14 11 14 ** Minnesota 10 11 6 7 9 11 * 10 11 12 9 11 * Mississippi 24 22 13 9 ** 18 22 ** 21 16 15 18 20 * Missouri 16 19 * 9 11 * 14 15 15 16 16 17 15 * Montana 20 26 ** 12 12 13 15 * 18 21 20 15 17 * Nebraska 15 17 9 9 10 13 * 14 17 18 12 15 ** Nevada 21 29 ** 16 20 ** 14 19 ** 17 22 15 ** 16 20 ** New Hampshire 14 17 * 5 7 * 10 13 * 11 12 10 * 10 10 New Jersey 18 21 * 11 8 * 12 15 * 14 10 10 14 14 New Mexico 29 29 16 13 * 15 19 ** 19 18 20 * 17 18 New York 17 16 8 6 * 12 15 * 14 12 11 15 15 North Carolina 21 24 * 11 9 * 17 19 * 19 13 12 16 14 * North Dakota 14 14 8 5 * 6 9 * 13 15 14 11 14 ** Ohio 15 18 * 7 8 12 14 * 17 14 13 12 14 * Oklahoma 22 25 * 10 8 * 18 18 15 23 20 * 19 18 Oregon 21 21 11 7 ** 12 18 ** 19 17 19 * 14 15 Pennsylvania 12 15 * 7 8 9 13 ** 13 12 12 12 13 Rhode Island 14 17 * 8 7 10 13 * 13 7 8 10 12 * South Carolina 20 22 14 12 * 15 21 ** 17 14 16 * 17 18 South Dakota 15 19 * 9 8 9 11 * 14 16 15 13 11 * Tennessee 20 19 9 7 * 15 19 ** 20 8 10 * 17 17 Texas 31 32 20 16 ** 19 21 * 17 15 18 * 20 18 * Utah 15 20 * 10 10 12 15 * 22 22 20 * 15 16 Vermont 13 11 7 5 * 10 10 13 14 13 12 11 Virginia 17 18 9 6 * 11 15 ** 13 14 12 * 13 12 Washington 15 20 * 7 7 12 15 * 16 17 18 13 14 West Virginia 21 20 5 9 ** 17 19 * 17 10 11 14 18 ** Wisconsin 12 14 6 6 8 13 ** 14 15 9 ** 11 12 Wyoming 18 22 * 9 10 12 15 * 19 23 20 * 14 14 Change 20 23 42 — 25 25 States Improved 0 17 0 — 14 7 States Worsened 20 6 42 — 11 18 Notes: * denotes a change of at least 0.5 standard deviation; ** denotes a change of 1.0 standard deviation or more. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 38 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix Exhibit A5. Prevention & Treatment: Dimension and Indicator Ranking e Performance Quartile sk om t ra -ri ith l ta ds od l gh tte rh ar al en w Top Quartile un st l pa ta er o ye ug hi fo ith be re ts ar m id d g d e n n wo n an en ca dr a tio a de ns th de s sw y e ed nd et e e ov e d ip d ar sid io h io io e n of m Second Quartile en pr n c ou g ve cr ve st ed nd at it ip en cine nth at os lc ct ho ar ho ic s w e re ie m ei es ei pa e y er h sit l a ru ita rc lit e dn ith r c o om ec pr r ec in ts w op s w al e w pe ou vi ca ed t st va m in m ta sp Third Quartile m en ic ug r th ve in n ex re ec n nt re di dr ho te ho s o ls or d 35 ed ho ov n ic sid re h ca e in ei g ge r a ie m tie ca r ua m tio ts n w ca w 9– m e am so ing e ith re rec d te at ot re ica n ar Bottom Quartile or pa d us y di ts tio ts re en 1 a ie af h p da tiv w ch e r y ch re rs in en m es te ith tiv h ca o de un pat a s y om ng th en lts su nu en wit th h 0- ve is ed l t m ag en ith r a ti cr ti al n w w ki al al ea co l d l3 ev du es pa n t pa tip h om re es sk al e -c w n ev n co n an ing w eh he e h ita re pita pr a co ica nt he re re re re pr dre pr -ri pr rly co rly ts er ild ild ild sp tie gh m m ul rs ed de de RANK il s ld Nu Ho Ho Ho Ho Ad Ch Ch Ch Ch Pa Hi M El El O 1 Massachusetts 1 1 1 1 2 1 1 1 1 1 1 3 1 1 1 3 2 Maine 1 1 1 1 1 1 1 1 1 3 1 1 1 3 1 3 3 New Hampshire 1 1 1 1 2 1 1 2 1 4 1 1 3 4 1 3 3 Rhode Island 1 1 2 1 2 1 1 1 1 4 2 3 1 1 2 2 3 Wisconsin 2 2 1 3 2 1 1 1 1 3 1 1 4 3 1 1 6 Iowa 1 2 1 2 2 1 1 2 3 3 2 1 2 3 1 2 6 Minnesota 3 1 1 4 1 3 1 1 1 1 1 1 4 4 1 1 8 Colorado 3 2 3 2 2 2 2 2 2 1 1 1 2 2 1 1 8 Connecticut 1 1 2 1 2 1 1 1 1 1 3 4 3 2 1 3 8 Delaware 1 1 3 2 1 1 2 1 1 1 3 4 3 4 1 2 8 Vermont 1 1 1 1 1 4 1 1 3 4 1 1 3 4 1 3 12 Michigan 1 2 2 3 1 2 2 2 3 1 1 2 2 4 2 1 12 Nebraska 2 3 1 2 1 1 2 3 1 2 1 1 3 4 1 3 12 Pennsylvania 1 2 2 1 1 3 1 2 1 2 3 4 1 4 2 2 15 Maryland 1 1 2 1 3 3 2 2 2 1 3 4 2 2 3 1 16 South Dakota 3 2 1 4 2 4 1 1 1 2 2 1 3 3 1 2 17 District of Columbia 2 2 4 1 3 1 2 2 1 1 4 4 3 1 4 1 17 Kansas 2 2 2 2 1 4 3 3 3 2 2 1 2 4 2 3 17 North Dakota 4 3 1 4 1 2 1 1 4 1 2 3 4 2 1 2 20 Hawaii 1 2 2 1 3 1 3 1 1 3 4 4 4 4 1 1 20 New Jersey 1 3 4 1 3 2 1 2 2 1 4 4 1 1 4 1 20 Ohio 2 3 2 2 2 3 2 3 2 2 2 3 2 3 2 4 23 Illinois 1 3 3 1 4 2 1 2 1 1 3 3 2 3 3 4 23 Wyoming 4 4 2 3 1 3 2 1 4 3 1 1 4 3 1 1 25 Kentucky 2 3 3 3 2 3 4 4 1 3 3 1 1 1 3 3 25 South Carolina 3 3 3 3 4 2 4 4 1 3 2 1 1 1 3 1 25 West Virginia 3 2 1 1 1 4 3 3 4 3 3 3 1 1 3 2 28 Missouri 2 2 1 3 2 4 3 3 1 2 2 3 2 3 2 4 28 Montana 4 4 2 4 3 3 2 3 1 1 3 3 4 1 1 2 28 New York 1 2 4 1 2 4 1 1 3 2 4 4 3 3 4 2 28 North Carolina 3 1 3 3 4 1 4 3 2 3 2 1 2 2 4 1 28 Utah 4 3 1 4 4 1 3 4 3 3 1 1 1 1 2 4 28 Virginia 3 1 2 2 4 2 3 3 3 3 2 4 1 2 3 3 34 Tennessee 2 3 2 2 3 1 4 4 3 3 3 2 2 2 2 4 35 Indiana 2 4 2 3 3 4 3 3 2 3 2 2 3 3 3 3 35 Oregon 3 3 2 4 2 3 2 2 4 4 2 3 4 2 3 2 35 Washington 3 2 2 2 4 4 2 2 4 4 2 3 4 3 2 2 38 Alabama 2 2 3 2 4 2 4 4 4 3 4 2 1 1 2 4 38 Florida 3 3 4 4 3 2 2 3 2 2 4 4 1 1 2 3 38 Idaho 4 4 2 4 4 4 3 4 4 3 1 1 2 2 1 3 41 California 4 3 4 3 2 3 2 3 4 1 4 4 3 1 3 1 41 Louisiana 3 3 3 3 4 2 4 4 1 3 3 1 2 1 4 4 43 Alaska 4 3 4 4 2 4 2 3 2 3 2 2 4 4 1 1 43 Georgia 4 1 4 3 4 1 4 4 2 3 4 3 2 2 3 4 45 Arizona 4 4 4 3 3 3 2 1 4 1 2 3 4 4 3 3 45 Mississippi 4 4 4 4 4 1 4 4 1 4 4 2 1 1 3 4 45 New Mexico 4 4 4 2 3 2 3 3 4 2 4 3 3 1 3 2 45 Oklahoma 3 4 3 4 3 4 4 4 2 2 3 1 2 1 4 4 49 Texas 4 3 4 3 3 4 4 3 3 2 3 1 4 2 3 4 50 Arkansas 3 4 3 4 1 3 4 4 4 4 4 3 3 2 3 4 51 Nevada 4 4 4 4 4 4 3 2 4 4 3 4 3 1 3 2 Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org39 Appendix Exhibit A6. Prevention & Treatment: Dimension Ranking and Indicator Rates Children with a medical and dental Children who Older adults with preventive care received needed Adults with a usual recommended Children with a visit in the mental health care source of care preventive care medical home past year in the past year 2007 2012 2006 2012 2007 2011/12 2011/12 2007 2011/12 United States 80% 78% 44% 42% * 58% 54% * 68% 60% 61% Alabama 82 80 39 43 * 56 54 70 62 54 * Alaska 72 63 ** 40 39 52 52 59 63 63 Arizona 76 75 42 35 ** 50 46 * 65 62 60 Arkansas 84 78 ** 37 34 * 61 55 ** 62 56 67 ** California 72 73 38 41 * 50 45 * 65 54 63 ** Colorado 79 77 47 44 * 59 55 * 70 65 65 Connecticut 87 86 51 47 * 62 58 * 79 79 65 ** Delaware 90 87 * 52 48 * 60 56 * 72 77 67 ** District of Columbia 80 79 43 44 50 50 77 56 59 Florida 78 76 41 39 * 57 50 ** 60 52 58 * Georgia 80 75 * 45 46 58 52 ** 65 51 53 Hawaii 88 85 * 41 44 * 60 57 * 73 63 58 * Idaho 73 71 37 35 * 56 57 59 63 56 * Illinois 82 83 38 39 56 56 74 53 55 Indiana 84 82 39 37 * 62 58 * 69 64 58 * Iowa 84 83 46 45 67 67 70 75 66 ** Kansas 84 79 * 43 45 * 61 59 70 72 72 Kentucky 85 81 * 43 41 * 62 56 ** 68 66 66 Louisiana 79 77 38 41 * 55 56 67 55 40 ** Maine 89 88 49 47 * 66 63 * 73 71 78 * Maryland 84 84 50 48 * 59 57 73 59 59 Massachusetts 89 89 50 52 * 66 63 * 79 67 65 Michigan 86 84 51 45 ** 63 59 * 68 60 68 * Minnesota 80 76 * 52 47 ** 63 61 60 67 72 * Mississippi 77 74 * 37 38 52 49 * 60 43 53 ** Missouri 84 79 * 46 43 * 65 62 * 65 74 63 ** Montana 72 73 45 36 ** 62 58 * 61 68 60 * Nebraska 84 82 42 41 69 61 ** 70 71 71 Nevada 72 67 * 40 37 * 45 45 56 53 49 * New Hampshire 88 88 49 48 69 67 79 63 66 New Jersey 86 83 * 44 41 * 57 53 * 76 55 58 New Mexico 75 70 * 39 36 * 49 48 70 53 58 * New York 84 83 46 44 * 57 53 * 73 61 64 North Carolina 78 76 48 46 * 61 55 ** 67 62 54 * North Dakota 78 74 * 43 42 64 62 61 72 86 ** Ohio 85 81 * 46 41 ** 66 57 ** 71 66 66 Oklahoma 79 76 * 36 38 * 56 56 62 54 61 * Oregon 78 78 44 39 ** 63 57 ** 63 46 66 ** Pennsylvania 90 87 * 45 44 62 59 * 73 81 69 ** Rhode Island 85 87 51 46 ** 64 60 * 76 76 66 ** South Carolina 82 78 * 43 42 59 54 * 64 63 50 ** South Dakota 81 78 * 46 43 * 63 62 59 69 64 * Tennessee 85 79 ** 46 41 ** 61 60 70 64 60 * Texas 72 68 * 40 39 50 52 68 42 59 ** Utah 78 74 * 40 40 63 64 61 67 49 ** Vermont 87 88 49 47 * 67 69 81 69 78 ** Virginia 80 78 51 46 ** 59 57 70 72 53 ** Washington 79 77 46 43 * 60 59 72 62 54 * West Virginia 79 76 * 43 44 65 61 * 74 72 74 Wisconsin 86 82 * 47 43 * 63 66 * 68 61 65 * Wyoming 74 69 * 38 36 * 59 59 65 68 67 Change 25 37 28 — 34 States Improved 0 7 1 — 14 States Worsened 25 30 27 — 20 Notes: * denotes a change of at least 0.5 standard deviation; ** denotes a change of 1.0 standard deviation or more. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 40 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix Exhibit A6. Prevention & Treatment: Dimension Ranking and Indicator Rates (continued) Elderly patients who received Medicare patients Children ages 19–35 months Elderly patients who received a contraindicated experienced good with all recommended vaccines a high-risk prescription drug prescription drug communication with provider 2009 2012 2007 2011 2007 2011 2007 2013 United States 44% 68% ** 29% 20% ** 20% 23% * 75% 76% * Alabama 47 71 ** 42 29 ** 27 29 * 75 74 * Alaska 53 60 * 26 19 * 16 21 ** 75 76 * Arizona 37 68 ** 28 19 ** 18 18 72 74 * Arkansas 34 66 ** 40 25 ** 23 26 * 75 72 ** California 50 67 ** 26 19 * 20 22 * 72 74 * Colorado 47 72 ** 26 19 * 18 19 75 76 * Connecticut 34 77 ** 20 14 * 17 17 74 77 ** Delaware 39 73 ** 26 18 ** 19 16 * 78 79 * District of Columbia 48 73 ** 19 17 14 19 ** 75 79 ** Florida 49 69 ** 30 19 ** 20 22 * 73 76 ** Georgia 46 75 ** 39 25 ** 25 24 72 76 ** Hawaii 47 80 ** 22 21 15 18 * 77 77 Idaho 34 63 ** 32 22 ** 21 24 * 73 74 * Illinois 54 69 ** 24 15 ** 17 19 * —a 77 Indiana 43 61 ** 32 20 ** 21 22 75 76 * Iowa 42 75 ** 22 15 * 17 19 * 75 75 Kansas 46 65 ** 30 20 ** 21 22 76 75 * Kentucky 43 68 ** 36 26 ** 26 27 73 77 ** Louisiana 54 69 ** 41 28 ** 25 26 77 80 ** Maine 38 73 ** 21 13 ** 14 14 77 77 Maryland 45 67 ** 23 16 * 19 19 75 76 * Massachusetts 33 74 ** 16 12 * 15 16 75 77 * Michigan 52 71 ** 27 16 ** 18 20 * 75 75 Minnesota 42 66 ** 19 13 * 15 17 * 77 78 * Mississippi 59 78 ** 44 29 ** 26 27 77 78 * Missouri 31 64 ** 32 20 ** 21 23 * 72 77 ** Montana 39 67 ** 26 17 ** 22 22 76 77 * Nebraska 38 73 ** 29 18 ** 20 21 73 79 ** Nevada 39 65 ** 28 21 * 17 20 * 74 73 * New Hampshire 39 80 ** 21 14 * 18 20 * 74 78 ** New Jersey 45 72 ** 21 15 * 18 20 * 74 76 * New Mexico 46 72 ** 30 22 ** 19 23 ** 72 73 * New York 48 64 ** 18 13 * 16 18 * 75 75 North Carolina 40 75 ** 35 23 ** 22 23 74 76 * North Dakota 43 72 ** 23 14 ** 15 16 71 73 * Ohio 45 67 ** 29 19 ** 21 22 74 76 * Oklahoma 52 61 * 39 27 ** 25 27 * 70 76 ** Oregon 44 67 ** 28 19 ** 18 19 72 74 * Pennsylvania 39 68 ** 24 15 ** 17 19 * 77 78 * Rhode Island 29 73 ** 19 14 * 15 16 78 77 * South Carolina 35 72 ** 38 24 ** 24 24 78 77 * South Dakota 43 64 ** 25 13 ** 17 18 73 77 ** Tennessee 45 73 ** 39 27 ** 26 26 75 75 Texas 41 65 ** 36 23 ** 22 23 74 75 * Utah 41 73 ** 29 21 ** 22 26 ** 69 75 ** Vermont 23 63 ** 17 12 * 14 17 * 75 75 Virginia 40 70 ** 30 20 ** 20 21 75 75 Washington 36 65 ** 25 19 * 18 19 70 74 ** West Virginia 30 61 ** 30 22 ** 18 22 ** 74 73 * Wisconsin 39 75 ** 20 13 * 15 16 75 78 ** Wyoming 44 67 ** 30 17 ** 21 18 * 71 74 ** Change 51 49 25 42 States Improved 51 49 2 35 States Worsened 0 0 23 7 Notes: * denotes a change of at least 0.5 standard deviation; ** denotes a change of 1.0 standard deviation or more. (a) Previous data are not shown because of changes in the indicators’ definitions or data were not available. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org41 Appendix Exhibit A6. Prevention & Treatment: Dimension Ranking and Indicator Rates (continued) Home health Home health Nursing home Hospital patients who patients whose High-risk residents discharge Patient- get better wounds nursing home with an Hospital 30-day instructions for centered at walking or healed after residents with antipsychotic mortality home recovery hospital care moving around an operation pressure sores medication 07/2005– 07/2008– 04/2012– 07/2012– 04/2012– 06/2008 06/2011 2007 2011 2007 2011 04/2012–03/2013 03/2013 03/2013 03/2013 United States 13% 13% 79% 83% ** 62% 66% ** 59% 89% 6% 22% Alabama 12.6 13.1 ** 87 81 ** 69 67 * 63 92 6 25 Alaska 12.4 12.9 ** 82 85 * 63 67 ** 49 82 5 13 Arizona 12.5 12.5 78 84 ** 61 65 ** 56 84 7 22 Arkansas 13.6 13.5 77 81 ** 64 66 * 58 90 7 26 California 12.9 12.5 * 76 81 ** 57 62 ** 58 91 7 19 Colorado 12.1 12.3 81 86 ** 63 68 ** 60 89 5 19 Connecticut 12.1 12.4 * 80 82 * 61 63 * 57 89 5 24 Delaware 12.4 12.2 80 82 * 62 64 * 57 84 5 20 District of Columbia 11.8 12.2 * 76 77 55 57 * 58 95 9 18 Florida 12.5 12.7 75 81 ** 55 61 ** 63 92 6 23 Georgia 13.1 13.1 78 81 * 62 66 ** 60 89 7 25 Hawaii 13.2 13.1 74 81 ** 57 64 ** 53 81 3 12 Idaho 13.4 12.9 ** 82 87 ** 62 69 ** 60 90 4 23 Illinois 12.3 12.5 79 83 ** 61 65 ** 59 88 7 26 Indiana 12.8 12.9 81 84 * 64 67 * 58 88 7 22 Iowa 12.6 12.8 82 85 * 64 68 ** 60 87 5 21 Kansas 12.3 12.6 * 79 85 ** 63 69 ** 59 86 6 24 Kentucky 12.5 13.0 ** 79 83 ** 64 68 ** 62 91 7 24 Louisiana 12.7 13.0 * 79 83 ** 66 71 ** 59 93 9 29 Maine 12.8 12.9 84 86 * 67 70 * 62 88 5 24 Maryland 12.3 12.2 76 82 ** 57 61 ** 60 90 7 18 Massachusetts 11.9 11.9 84 86 * 63 66 * 62 91 5 24 Michigan 12.5 12.4 81 86 ** 63 67 ** 59 86 6 16 Minnesota 11.9 12.2 * 82 86 ** 65 69 ** 56 83 4 18 Mississippi 12.9 13.2 * 76 79 * 64 67 * 63 92 7 26 Missouri 12.6 12.7 80 84 ** 62 65 * 60 88 6 25 Montana 12.0 12.5 ** 78 82 ** 64 66 * 55 91 5 20 Nebraska 12.6 12.7 82 87 ** 66 69 * 57 83 5 23 Nevada 13.4 13.2 73 82 ** 52 61 ** 58 92 7 20 New Hampshire 13.8 13.3 ** 85 88 * 67 69 * 58 86 4 24 New Jersey 12.4 12.3 75 79 ** 59 61 * 62 91 9 17 New Mexico 12.6 12.7 77 81 ** 61 66 ** 58 91 7 21 New York 13.0 12.6 * 79 81 * 59 61 * 58 88 8 20 North Carolina 13.0 13.1 81 84 * 66 68 * 59 89 8 19 North Dakota 11.9 12.4 ** 81 84 * 61 65 ** 54 89 5 20 Ohio 12.6 12.6 80 85 ** 62 66 ** 59 88 6 25 Oklahoma 12.7 12.6 81 82 65 68 * 59 91 8 25 Oregon 13.4 13.3 81 84 * 64 66 * 55 89 7 20 Pennsylvania 12.6 12.6 79 83 ** 61 64 * 61 86 6 21 Rhode Island 12.7 13.2 ** 81 84 * 62 65 * 61 93 6 21 South Carolina 12.9 13.1 79 85 ** 62 68 ** 62 92 7 19 South Dakota 12.4 12.6 79 85 ** 65 71 ** 57 87 5 20 Tennessee 13.1 12.9 78 82 ** 62 67 ** 60 90 6 27 Texas 12.7 12.6 78 83 ** 61 68 ** 55 89 7 28 Utah 12.5 12.9 * 81 89 ** 64 68 ** 63 91 6 28 Vermont 14.1 13.6 ** 84 87 * 68 68 58 86 5 23 Virginia 13.0 13.1 80 84 ** 61 64 * 61 90 7 22 Washington 13.5 13.4 81 85 ** 62 65 * 55 88 6 21 West Virginia 12.9 13.0 79 83 ** 64 65 62 91 7 21 Wisconsin 12.9 12.9 84 87 * 67 69 * 56 87 5 18 Wyoming 12.0 12.8 ** 84 86 * 66 68 * 56 88 5 18 Change 19 49 49 — — — — States Improved 5 48 48 — — — — States Worsened 14 1 1 — — — — Notes: * denotes a change of at least 0.5 standard deviation; ** denotes a change of 1.0 standard deviation or more. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 42 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix A7. Avoidable Hospital Use & Cost: Dimension and Indicator Ranking Performance Quartile r, – Top Quartile r- de re a ye , ol ca 4, pi ith ns ith 00 g iss d in 65 y –7 s lo ,0 on io d ry es or os s w Second Quartile w l n an p ta iss an o io s a g la t am dm lle pl r em ts s 5 lat re ric e h nt dm en l a ro rie s, u th de rie 7 u ild iat pe s ia on b Third Quartile ita en s, sit o n fo ia ge b e n sid r1 s rea fic iti am to si le ch ed fic a m ) re B ie vi pe ium n re sp so re ol s, r a 00 p pe & rie l ne nd for s iar D ia ita nr io e ho al n e ,0 for on fo ts ts A Bottom Quartile rie c E iss hom gl rem io om rs fic sp a s ns ia efi ble iti ns nt 00 s ne ho en r iss g h 00 ve io r 1 ion sin p 00 nd io ith ie Pa fic en da dm g e- be co ,0 iti iss Data not available d ce ,0 co iss w at ea sin be ay dm in em ( pe iss ne e b oi ne rs e r 1 ns m re h p re an l a urs r 1 ve m 00 -d y r ur be icar y av ar a, m pe –se e ad be pe siti e ad ,0 30 so ur da n bu ic ica alt m d ita n im ed on ins th l a 0- y l sp tay r 1 re ed al ed e ta re r n r M eh ca ica as pita se ica re l M M nti pe ica a 3 t-s sp lth ho -s ed ng m ed te ed ta or RANK a s Ho Ho He Po To M Sh M Lo M 1 Hawaii 1 1 1 1 0 0 1 1 1 1 2 Oregon 1 1 1 1 2 1 1 1 1 1 3 Idaho 0 1 1 1 1 1 1 1 1 1 4 Utah 1 1 1 1 1 1 1 1 3 2 5 Washington 2 1 1 1 2 1 1 1 1 1 6 Montana 2 1 1 1 1 1 1 1 3 1 7 Minnesota 1 1 1 2 1 1 2 1 1 1 7 New Mexico 0 2 1 1 2 2 1 2 2 1 7 South Dakota 2 1 2 1 1 2 1 1 2 1 10 Colorado 3 1 1 1 1 1 1 2 2 1 11 Vermont 1 1 2 1 1 1 1 3 2 1 12 Alaska 1 1 1 1 0 0 2 2 3 1 12 New Hampshire 0 2 2 1 1 1 1 3 2 2 14 California 2 1 1 2 2 3 1 1 1 2 14 Nebraska 1 2 2 2 1 2 2 1 2 2 14 North Dakota 0 2 2 2 2 2 1 2 2 2 17 Arizona 3 1 1 2 3 1 1 2 1 2 18 Iowa 1 2 2 2 2 2 2 2 3 2 19 Nevada 2 2 2 2 4 3 1 1 1 2 19 Wisconsin 2 1 2 2 1 1 2 3 4 2 19 Wyoming 3 2 2 1 1 2 4 1 4 1 22 Delaware 0 2 3 2 2 2 1 2 2 3 22 Maine 1 2 2 2 1 2 1 4 4 2 24 Rhode Island 4 2 2 3 3 1 1 3 2 3 24 South Carolina 3 2 2 2 2 2 1 2 4 3 26 Connecticut 2 2 4 3 2 2 2 4 1 3 26 Kansas 3 2 3 2 2 3 2 1 3 3 28 Virginia 3 2 3 3 2 3 2 3 3 2 29 North Carolina 3 3 2 3 2 2 2 3 4 2 30 Massachusetts 4 3 4 3 2 2 2 4 1 3 30 New Jersey 4 2 3 4 4 4 1 1 1 4 30 Texas 2 3 4 3 4 4 1 2 3 4 33 Florida 4 3 3 3 3 4 1 2 3 4 33 Georgia 2 3 3 3 4 3 2 3 3 3 33 Maryland 4 3 3 3 4 3 2 3 2 2 36 New York 4 3 3 4 3 2 4 2 1 3 37 Arkansas 1 4 4 3 4 4 4 3 2 3 37 Pennsylvania 4 3 3 3 3 2 2 3 3 4 39 Illinois 3 3 3 4 4 4 2 3 2 4 39 Michigan 2 4 3 4 3 3 1 4 3 4 39 Missouri 4 3 3 3 3 3 2 3 4 3 42 District of Columbia 0 4 3 4 0 0 2 4 2 3 43 Indiana 3 4 4 3 2 3 4 4 4 4 43 Tennessee 2 4 4 3 3 4 4 3 4 3 45 Ohio 3 4 4 4 3 2 4 4 3 4 45 Oklahoma 4 4 4 3 4 4 2 4 3 4 47 Alabama 0 4 4 3 3 3 4 3 4 4 48 West Virginia 3 4 4 4 3 3 4 4 4 3 49 Kentucky 4 4 4 4 3 4 4 4 4 4 50 Louisiana 4 4 4 4 4 4 1 4 4 4 50 Mississippi 0 4 4 4 4 4 4 4 4 4 Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org43 Appendix Exhibit A8. Avoidable Hospital Use & Cost: Dimension Ranking and Indicator Rates Medicare admissions for Medicare admissions for Hospital admissions ambulatory care–sensitive ambulatory care–sensitive Medicare 30-day hospital for pediatric asthma, conditions, ages 65–74, conditions, age 75 and older, readmissions, per 1,000 per 100,000 children per 1,000 beneficiaries per 1,000 beneficiaries beneficiaries 2004 2010 2008 2012 2008 2012 2008 2012 United States 156 130 * 36 29 * 85 70 * 58 49 * Alabama —a —a 47 38 ** 100 81 ** 64 50 ** Alaska —a 54 26 21 * 68 52 ** 34 29 Arizona 131 121 24 20 62 51 * 47 38 * Arkansas 117 70 ** 41 35 * 103 82 ** 59 51 * California 105 93 26 21 * 70 55 * 49 43 * Colorado 167 129 * 23 16 * 68 50 ** 41 31 * Connecticut 149 110 * 31 26 * 84 75 * 58 52 * Delaware —a —a 26 27 69 68 51 42 * District of Columbia —a —a 45 37 * 80 73 70 65 Florida 183 147 * 31 28 76 68 * 57 54 Georgia 145 91 ** 37 31 * 85 73 * 51 45 * Hawaii 88 56 * 20 13 * 48 41 31 26 Idaho —a —a 23 17 * 63 45 ** 30 26 Illinois 129 116 40 31 ** 95 73 ** 74 58 ** Indiana 122 113 42 35 * 91 77 * 56 51 Iowa 81 75 32 24 * 80 64 ** 51 39 ** Kansas 147 142 36 27 ** 90 70 ** 55 43 ** Kentucky 213 184 * 56 50 * 110 100 * 71 63 * Louisiana —a 201 52 44 * 119 97 ** 69 56 ** Maine —a 62 30 26 76 65 * 48 39 * Maryland 161 165 38 29 ** 86 69 ** 72 54 ** Massachusetts 143 179 * 39 30 ** 97 80 ** 67 54 ** Michigan 175 112 ** 39 33 * 87 73 * 69 61 * Minnesota 122 71 ** 23 20 68 55 * 50 41 * Mississippi —a —a 52 42 ** 117 91 ** 68 55 ** Missouri 171 159 40 31 ** 91 73 ** 64 51 ** Montana —a 77 30 21 ** 78 58 ** 43 30 ** Nebraska 102 63 * 34 24 ** 83 63 ** 51 39 ** Nevada 125 112 30 24 * 73 60 * 48 41 * New Hampshire 54 —a 31 23 * 75 64 * 43 36 * New Jersey 176 159 36 27 ** 88 73 * 71 57 ** New Mexico —a —a 28 23 * 69 58 * 38 33 New York 284 223 ** 35 28 * 88 73 * 69 59 * North Carolina 131 119 35 29 * 78 67 * 51 45 * North Dakota —a —a 31 23 * 76 65 * 45 41 Ohio 114 136 * 43 38 * 94 82 * 67 59 * Oklahoma —a 149 47 38 ** 101 80 ** 59 49 * Oregon 49 49 21 17 57 48 * 34 28 * Pennsylvania —a 183 36 31 * 89 74 * 66 54 ** Rhode Island 154 192 * 37 27 ** 91 66 ** 64 49 ** South Carolina 192 143 ** 34 27 * 78 65 * 48 41 * South Dakota 91 84 26 22 80 65 * 41 36 Tennessee 156 101 ** 47 37 ** 104 84 ** 64 53 * Texas 159 108 ** 38 31 * 92 76 ** 54 46 * Utah 81 66 20 17 46 42 29 28 Vermont 43 26 27 22 * 70 65 36 33 Virginia 152 115 * 32 27 * 76 71 52 48 Washington 92 90 22 18 59 49 * 38 35 West Virginia 171 117 ** 53 49 111 98 * 71 64 * Wisconsin 100 88 29 22 * 75 60 * 50 41 * Wyoming —a 123 33 24 ** 79 62 ** 43 34 * Change 19 41 45 38 States Improved 16 41 45 38 States Worsened 3 0 0 0 Notes: * denotes a change of at least 0.5 standard deviation; ** denotes a change of 1.0 standard deviation or more. (a) Previous data are not shown because of changes in the indicators’ definitions or data were not available. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 44 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix Exhibit A8. Avoidable Hospital Use & Cost: Dimension Ranking and Indicator Rates (continued) 30-day hospital Home health patients Potentially avoidable readmissions as a Short-stay nursing home Long-stay nursing home also enrolled in ED visits among percent of Medicare residents with a 30-day residents with a hospital Medicare with a Medicare beneficiaries, admissionsb readmission to the hospital admission hospital admission per 1,000 beneficiaries 2012 2006 2010 2006 2010 2012 2011 United States 18% 20% 20% 19% 19% 17% 185 Alabama 17 21 22 23 21 18 191 Alaska 14 —a —a —a —a 17 181 Arizona 16 22 22 10 12 16 175 Arkansas 18 24 24 28 27 18 185 California 18 20 20 19 21 15 166 Colorado 14 17 15 * 12 12 16 176 Connecticut 18 19 19 18 19 17 195 Delaware 17 22 20 * 20 19 16 175 District of Columbia 21 —a —a —a —a 17 263 Florida 18 21 21 24 25 16 172 Georgia 17 21 23 * 21 20 17 194 Hawaii 15 —a —a —a —a 15 129 Idaho 13 14 14 13 12 15 169 Illinois 19 23 23 26 25 17 191 Indiana 17 18 20 * 21 20 18 200 Iowa 15 18 17 17 16 17 177 Kansas 16 19 19 20 20 17 169 Kentucky 19 21 21 26 24 18 215 Louisiana 18 24 26 * 32 31 16 222 Maine 16 16 16 15 14 16 235 Maryland 19 23 23 21 20 17 185 Massachusetts 18 19 19 16 17 17 218 Michigan 19 23 22 20 20 16 208 Minnesota 16 17 16 7 7 17 165 Mississippi 18 20 23 * 31 31 18 229 Missouri 17 21 22 22 21 17 192 Montana 14 15 14 15 12 * 16 167 Nebraska 15 15 16 17 17 17 149 Nevada 18 22 23 16 20 * 16 167 New Hampshire 16 15 16 12 13 16 194 New Jersey 19 24 23 27 26 16 169 New Mexico 15 18 18 14 15 15 171 New York 20 22 22 21 19 18 172 North Carolina 17 19 19 20 19 17 194 North Dakota 16 15 18 * 15 14 15 179 Ohio 18 21 21 20 17 * 18 215 Oklahoma 17 23 24 26 24 17 196 Oregon 14 17 17 10 10 15 164 Pennsylvania 18 20 21 19 17 17 185 Rhode Island 18 22 21 14 12 15 194 South Carolina 16 18 20 * 20 19 16 172 South Dakota 14 14 13 15 16 15 168 Tennessee 18 21 21 25 24 18 193 Texas 17 22 23 25 24 15 180 Utah 13 13 12 11 11 14 147 Vermont 16 13 15 * 12 13 16 194 Virginia 18 20 20 21 20 17 183 Washington 15 16 17 14 13 16 154 West Virginia 20 22 22 24 20 * 19 230 Wisconsin 16 17 16 14 13 17 184 Wyoming 15 15 15 14 14 18 168 Change 9 4 — — States Improved 2 3 — — States Worsened 7 1 — — Notes: * denotes a change of at least 0.5 standard deviation; ** denotes a change of 1.0 standard deviation or more. (a) Previous data are not shown because of changes in the indicators’ definitions or data were not available. (b) Not a scored indicator, included here for informational purposes only. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org45 Appendix Exhibit A9. Avoidable Hospital Use & Cost: Cost Indicators Total Medicare (Parts A & B) Health insurance premium for reimbursements per enrolleea employer-sponsored single-person plans Unadjusted Adjustedb Average annual Unadjusted Adjustedb Average annual 2008 2012 2008 2012 growth ratec 2008 2012 2008 2012 growth ratec United States $8,713 $9,396 $8,336 $8,874 1.9% $4,386 $5,384 $4,452 $5,431 5.3% Alabama 8,302 8,675 8,922 9,336 1.1% 4,139 4,961 5,042 6,043 4.6% Alaska 7,123 7,675 5,631 5,406 1.9% 5,293 7,420 4,096 5,742 8.8% Arizona 7,804 8,577 7,498 8,004 2.4% 4,214 5,196 4,122 5,082 5.4% Arkansas 7,580 8,150 8,056 8,635 1.8% 3,923 4,459 4,605 5,235 3.3% California 9,324 10,231 7,719 8,315 2.3% 4,280 5,422 3,300 4,180 6.1% Colorado 7,408 7,873 7,202 7,467 1.5% 4,303 5,275 4,203 5,153 5.2% Connecticut 9,855 10,572 8,231 8,950 1.8% 4,740 5,934 3,848 4,817 5.8% Delaware 8,775 9,329 8,136 8,513 1.5% 4,733 5,583 4,434 5,231 4.2% District of Columbia 9,883 10,915 8,279 8,894 2.5% 4,890 5,581 4,637 5,292 3.4% Florida 10,097 10,679 10,064 10,593 1.4% 4,517 5,179 4,820 5,527 3.5% Georgia 7,909 8,649 7,915 8,837 2.3% 4,160 5,159 4,511 5,594 5.5% Hawaii 5,958 6,421 5,149 5,417 1.9% 3,831 5,076 3,361 4,454 7.3% Idaho 6,502 7,355 6,714 7,196 3.1% 4,104 4,439 4,466 4,830 2.0% Illinois 9,053 9,785 8,583 9,253 2.0% 4,643 5,404 4,618 5,375 3.9% Indiana 8,196 9,012 8,333 9,221 2.4% 4,495 5,504 4,795 5,871 5.2% Iowa 6,933 7,687 7,180 7,494 2.6% 4,146 5,141 4,439 5,505 5.5% Kansas 7,802 8,467 8,253 8,582 2.1% 4,197 4,968 4,730 5,599 4.3% Kentucky 8,348 8,962 8,563 9,344 1.8% 4,009 5,397 4,646 6,255 7.7% Louisiana 9,892 10,322 10,573 10,873 1.1% 4,055 5,381 4,787 6,352 7.3% Maine 7,341 8,004 7,239 7,601 2.2% 4,910 5,692 5,176 6,000 3.8% Maryland 9,991 10,655 9,036 8,488 1.6% 4,360 5,302 4,362 5,305 5.0% Massachusetts 9,954 10,910 8,587 9,042 2.3% 4,836 6,121 3,577 4,527 6.1% Michigan 9,494 10,118 8,911 9,559 1.6% 4,388 5,365 4,528 5,537 5.2% Minnesota 7,057 7,916 6,791 7,217 2.9% 4,432 5,338 4,129 4,973 4.8% Mississippi 8,883 9,485 9,473 10,038 1.7% 4,124 4,713 5,027 5,745 3.4% Missouri 7,997 8,597 8,225 8,701 1.8% 4,124 5,150 4,636 5,789 5.7% Montana 6,424 6,932 6,746 6,589 1.9% 4,355 5,585 4,355 5,585 6.4% Nebraska 7,639 8,371 7,822 8,061 2.3% 4,392 5,101 4,605 5,348 3.8% Nevada 8,456 9,206 7,838 8,335 2.1% 3,927 4,949 3,457 4,357 6.0% New Hampshire 7,684 8,437 7,155 7,622 2.4% 5,247 5,688 4,734 5,132 2.0% New Jersey 10,325 10,958 8,851 9,551 1.5% 4,798 5,837 3,955 4,811 5.0% New Mexico 6,713 7,240 6,558 6,807 1.9% 4,074 5,035 4,268 5,274 5.4% New York 10,278 10,944 8,393 8,997 1.6% 4,638 6,033 3,882 5,050 6.8% North Carolina 7,703 8,288 7,565 8,254 1.8% 4,460 5,632 4,937 6,234 6.0% North Dakota 6,398 7,635 6,972 7,528 4.5% 3,830 5,377 3,830 5,377 8.9% Ohio 8,690 9,518 8,703 9,552 2.3% 4,089 5,081 4,477 5,564 5.6% Oklahoma 8,378 8,874 8,912 9,190 1.4% 4,072 4,851 4,736 5,642 4.5% Oregon 6,393 7,005 6,056 6,291 2.3% 4,384 5,460 3,973 4,948 5.6% Pennsylvania 8,958 9,762 8,757 9,383 2.2% 4,499 5,385 4,703 5,629 4.6% Rhode Island 8,957 9,586 7,965 8,539 1.7% 4,930 5,870 4,343 5,171 4.5% South Carolina 7,860 8,404 7,918 8,542 1.7% 4,477 5,098 5,046 5,746 3.3% South Dakota 6,416 7,617 6,622 7,250 4.4% 4,233 5,409 4,176 5,336 6.3% Tennessee 8,225 8,721 8,584 9,187 1.5% 4,276 5,067 4,939 5,852 4.3% Texas 9,521 10,143 9,594 10,152 1.6% 4,205 5,124 4,517 5,504 5.1% Utah 7,296 7,982 7,378 8,015 2.3% 4,197 5,162 4,498 5,532 5.3% Vermont 7,203 7,886 6,484 6,829 2.3% 4,900 5,580 4,827 5,497 3.3% Virginia 7,300 8,151 7,330 8,051 2.8% 4,202 5,309 4,466 5,642 6.0% Washington 7,170 7,908 6,571 7,101 2.5% 4,404 5,368 3,990 4,864 5.1% West Virginia 7,771 8,511 8,087 8,655 2.3% 4,892 5,884 5,967 7,177 4.7% Wisconsin 7,497 7,988 7,310 7,658 1.6% 4,777 5,737 4,858 5,834 4.7% Wyoming 6,637 7,710 6,681 6,818 3.8% 4,622 5,861 4,622 5,861 6.1% 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) Compounded average annual growth rate. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 46 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix A10. Healthy Lives: Dimension and Indicator Ranking e ity al h 75 se n et m tio Performance Quartile be 0 al e te 00 fe qu ag la ro re e 0, 0 pu Top Quartile or re ca d 00 to 10 te po m fo 0, th gh la er r be or 10 pe al 00 Second Quartile -re ei sp he six st w er ,0 hs th th lo er 00 sp e to at al st Third Quartile ea es ov ife r1 s de he lo th le e ob rd ll ok e ab pe ve n ea rth y, or ar tia ce Bottom Quartile e sm bi lit en ha Co tio d po ar hs ho tio n en e ta la cer m la l ca at ho ho ho e ith w liv or ot n ya de pu an w w w pu a n 0 m fp lif w ct re lit po c ts ts ts de 00 t of ults so po ore st ild 1, fan ta ul ul ul RANK ici ea or ar Ad Ad Ad Ch Ad l In Su Br Ye 1 Minnesota M 1 1 1 1 1 1 1 2 1 1 1 2 Massachusetts 1 1 1 2 1 1 1 1 1 3 2 3 Connecticut 1 1 2 1 1 2 1 1 1 2 1 4 Hawaii 2 1 1 1 3 2 1 1 1 1 1 4 Utah 1 2 3 1 4 1 1 1 1 1 1 6 Colorado 1 1 1 1 4 2 2 1 1 1 1 7 California 2 1 2 1 1 1 4 1 1 2 1 7 New Hampshire 1 1 2 1 3 1 2 1 2 1 2 7 New Jersey 2 1 3 3 1 1 1 1 1 1 2 7 Vermont 1 1 1 3 4 2 1 1 1 1 3 7 Washington 1 1 2 1 3 1 3 1 2 1 1 12 Nebraska 1 1 1 3 1 1 2 3 2 2 1 12 New York 3 1 2 2 1 1 2 1 1 3 2 12 Rhode Island 2 2 1 3 2 2 2 1 1 2 2 15 Idaho 1 2 2 1 4 2 3 1 2 2 1 15 Iowa 2 2 1 4 2 1 1 2 3 2 2 17 Wisconsin 2 2 2 2 2 2 1 3 3 2 3 18 Oregon 1 2 3 2 4 1 4 2 2 1 2 18 South Dakota 2 2 1 3 4 3 1 3 2 1 2 20 Maine 1 2 1 3 2 2 3 3 3 2 3 20 Montana 2 3 2 1 4 2 3 3 1 2 2 20 Virginia 3 2 3 2 1 3 2 2 2 2 2 23 Arizona 2 2 1 1 4 2 3 1 2 4 2 23 Florida 3 3 2 1 3 3 4 1 1 2 3 23 Kansas 2 3 1 2 3 3 2 2 3 2 2 23 Maryland 3 2 4 2 1 3 2 1 2 3 2 27 Illinois 3 2 3 3 1 3 2 2 2 3 2 27 Texas 3 3 2 2 1 2 3 2 3 4 1 29 Alaska 2 3 2 4 4 3 2 3 1 2 2 29 Delaware 3 3 3 2 1 4 2 3 2 3 2 29 North Dakota 2 2 3 4 3 3 1 3 3 4 1 29 Wyoming 3 3 3 3 4 2 1 3 1 1 3 33 New Mexico 2 4 3 1 4 1 4 2 3 3 2 33 Pennsylvania 3 3 4 3 2 3 2 3 3 1 3 35 District of Columbia 4 4 4 4 1 4 2 2 1 4 1 36 Nevada 4 3 4 4 4 2 4 2 2 3 3 36 North Carolina 3 3 4 2 2 4 3 3 4 3 3 38 Georgia 4 4 4 3 1 3 3 3 3 4 3 38 Michigan 3 3 4 2 2 4 3 4 4 3 3 40 Indiana 3 3 3 2 2 4 3 4 4 3 3 40 Missouri 3 4 4 3 3 3 3 4 3 2 3 42 Ohio 3 3 4 4 2 4 3 4 3 3 3 43 South Carolina 4 4 3 4 3 3 3 3 4 4 4 44 Kentucky 4 4 2 4 3 3 4 4 4 4 4 45 West Virginia 4 4 2 4 3 4 4 4 4 3 4 46 Oklahoma 4 4 4 3 4 4 4 4 4 3 4 46 Tennessee 4 4 3 4 3 4 4 4 4 3 4 48 Alabama 4 4 4 3 3 4 4 4 4 4 4 48 Arkansas 4 4 3 4 3 4 4 4 4 3 4 50 Louisiana 4 4 4 4 2 4 4 4 4 4 4 51 Mississippi 4 4 4 2 4 4 4 4 4 Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org47 Appendix Exhibit A11. Healthy Lives: Dimension Ranking and Indicator Rates Breast cancer deaths Colorectal cancer Suicide deaths Mortality amenable Years of potential life per 100,000 female deaths per 100,000 per 100,000 to health care lost before age 75 population population population 2004–05 2009–10 2005 2010 2005 2010 2005 2010 2005 2010 United States 96 86 * 7,153 6,474 * 24.2 22.1 * 17.7 15.8 ** 10.9 12.1 Alabama 117 114 9,776 9,254 27.4 23.6 ** 18.8 17.1 * 11.5 14.0 * Alaska 77 74 7,311 7,144 17.9 21.7 ** 15.2 17.4 ** 19.9 22.8 * Arizona 88 74 * 7,648 6,539 * 21.2 19.6 * 15.6 14.2 * 16.4 17.0 Arkansas 121 116 9,272 8,768 24.4 22.9 * 18.8 19.4 14.3 15.5 California 86 75 * 6,147 5,191 * 22.8 20.9 * 16.1 14.5 * 9.1 10.3 Colorado 72 62 * 6,204 5,615 22.3 20.0 * 16.7 13.7 ** 17.2 16.8 Connecticut 77 67 * 5,618 5,130 23.6 21.1 ** 15.4 12.6 ** 8.1 9.4 Delaware 97 90 7,560 7,154 23.6 23.2 18.1 15.0 ** 9.7 11.3 District of Columbia 158 119 ** 12,276 8,813 ** 29.2 29.9 21.0 19.4 * 5.4 6.9 Florida 91 83 7,714 6,886 * 22.4 21.5 16.5 14.5 ** 12.5 13.7 Georgia 114 103 * 8,267 7,312 * 23.6 23.8 17.8 16.6 * 10.6 11.7 Hawaii 80 78 5,877 5,619 19.5 14.8 ** 14.8 13.1 * 8.1 15.0 ** Idaho 74 67 6,212 5,943 19.4 21.8 ** 15.7 13.6 ** 16.5 18.8 * Illinois 101 90 * 6,911 6,229 * 25.8 22.7 ** 18.8 17.1 * 8.6 9.0 Indiana 101 93 7,621 7,242 22.8 22.9 19.5 16.1 ** 11.8 13.1 Iowa 79 74 5,903 5,691 21.4 19.5 * 18.4 17.8 11.2 12.1 Kansas 85 78 6,979 6,646 23.8 20.6 ** 18.7 15.9 ** 13.3 14.0 Kentucky 110 106 8,655 8,619 23.8 21.9 * 20.9 17.6 ** 13.4 14.2 Louisiana 137 123 * 10,529 9,005 ** 29.2 24.8 ** 20.1 18.3 * 11.0 12.3 Maine 78 67 * 6,498 5,893 22.6 20.3 * 17.5 16.4 * 12.4 13.2 Maryland 107 95 * 7,334 6,371 * 25.9 24.4 * 19.0 15.2 ** 8.4 8.3 Massachusetts 78 65 * 5,565 4,990 23.2 19.2 ** 17.9 14.9 ** 7.2 8.8 Michigan 102 90 * 7,352 7,038 24.1 23.8 18.4 15.8 ** 11.0 12.5 Minnesota 64 57 5,198 4,900 22.6 20.2 ** 15.0 14.3 10.5 11.2 Mississippi 142 136 10,898 9,781 * 26.1 25.0 20.2 20.5 12.7 13.0 Missouri 103 95 7,961 7,492 28.1 23.5 ** 18.4 17.2 * 12.5 14.0 Montana 73 73 7,442 6,967 23.6 21.1 ** 17.7 14.0 ** 21.7 21.8 Nebraska 72 67 5,971 5,555 24.0 19.3 ** 18.6 17.3 * 10.9 10.4 Nevada 112 97 * 8,146 6,952 * 24.1 23.8 18.6 17.4 * 19.8 19.8 New Hampshire 73 60 * 5,655 5,097 23.9 21.7 * 18.3 14.2 ** 12.0 14.1 * New Jersey 90 77 * 6,085 5,360 * 27.0 23.3 ** 19.1 16.3 ** 6.1 7.8 * New Mexico 83 81 8,053 7,609 22.5 22.2 16.4 14.3 ** 17.8 20.1 * New York 93 82 * 6,024 5,362 * 24.4 21.8 ** 17.1 15.4 * 6.0 7.7 * North Carolina 108 95 * 7,964 7,021 * 25.1 23.5 * 17.2 14.9 ** 11.4 12.0 North Dakota 73 75 6,097 6,099 22.8 23.0 18.9 17.6 * 13.7 15.6 * Ohio 106 94 * 7,536 7,158 26.5 24.1 ** 19.0 17.5 * 11.5 12.2 Oklahoma 115 112 9,181 8,864 25.2 24.9 19.5 16.5 ** 14.8 16.5 * Oregon 75 65 * 6,424 5,720 * 21.8 23.1 * 17.0 14.9 ** 14.9 17.1 * Pennsylvania 99 86 * 7,280 6,670 25.0 23.5 * 19.2 17.2 ** 11.1 11.9 Rhode Island 86 74 * 5,961 5,794 24.6 19.5 ** 17.4 16.6 6.3 12.3 ** South Carolina 115 102 * 9,156 8,204 * 26.2 22.5 ** 19.0 17.6 * 11.8 13.5 * South Dakota 81 71 * 7,074 6,475 24.0 19.7 ** 19.8 17.0 ** 15.4 17.5 * Tennessee 118 110 9,224 8,528 * 26.5 22.6 ** 19.3 17.7 * 14.0 14.6 Texas 100 94 7,224 6,594 23.1 21.0 * 16.9 15.9 * 10.9 11.7 Utah 64 62 5,885 5,720 24.3 22.4 * 13.4 12.0 * 15.4 18.3 * Vermont 68 58 * 5,687 4,997 * 20.6 19.3 * 18.0 16.7 * 12.5 15.7 * Virginia 96 85 * 6,807 6,014 * 25.9 22.3 ** 17.3 15.4 ** 11.2 11.7 Washington 74 65 5,895 5,357 23.2 21.2 * 15.5 14.1 * 12.8 13.9 West Virginia 112 107 9,017 9,038 27.0 20.9 ** 19.8 17.4 ** 13.2 14.1 Wisconsin 78 71 6,222 5,656 22.7 21.6 16.5 14.6 ** 11.6 13.4 * Wyoming 75 82 7,490 7,246 21.2 22.6 * 13.9 16.6 ** 17.3 22.4 ** Change 25 18 39 46 18 States Improved 25 18 35 44 0 States Worsened 0 0 4 2 18 Notes: * denotes a change of at least 0.5 standard deviation; ** denotes a change of 1.0 standard deviation or more. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 48 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix Exhibit A11. Healthy Lives: Dimension Ranking and Indicator Rates (continued) Infant mortality, Adults with poor Adults ages 18–64 deaths per 1,000 health-related Adults who Adults who Children who are who have lost live births quality of life smoke are obese overweight or obese six or more teeth 2004 2009 2007 2012 2007 2012 2007 2012 2007 2011/12 2006 2012 United States 6.8 6.4 24% 27% * 19% 19% 26% 28% * 32% 31% 10% 10% Alabama 8.7 8.3 30 36 ** 22 24 * 32 34 * 36 35 16 17 Alaska 6.6 6.9 27 26 22 20 * 28 26 * 34 30 ** 10 9 Arizona 6.7 6.0 * 25 29 ** 20 17 * 28 27 31 37 ** 9 10 Arkansas 8.4 7.6 * 28 33 ** 22 25 * 30 37 ** 37 34 * 13 16 * California 5.2 4.9 26 30 ** 14 12 * 24 26 * 31 30 8 7 Colorado 6.2 6.2 23 26 * 19 17 * 20 21 27 23 ** 6 7 Connecticut 5.4 5.6 20 23 * 15 16 23 26 * 26 30 ** 7 8 Delaware 8.6 8.0 25 24 19 20 29 27 * 33 32 10 10 District of Columbia 12.2 10.4 ** 22 24 * 17 19 * 22 23 35 35 8 7 Florida 7.0 6.9 23 30 ** 19 17 * 25 26 33 28 ** 12 12 Georgia 8.5 7.3 * 23 27 ** 16 20 ** 27 29 * 37 35 * 10 13 * Hawaii 5.8 5.9 22 23 17 15 * 23 26 * 28 27 7 6 Idaho 6.1 5.5 25 27 * 19 16 * 26 27 28 28 9 8 Illinois 7.5 6.9 24 26 * 19 18 25 28 * 35 34 8 9 Indiana 7.9 7.8 23 29 ** 23 24 27 32 ** 30 31 11 13 * Iowa 5.1 4.6 21 23 * 19 18 27 30 * 26 28 * 9 9 Kansas 7.3 7.1 21 25 ** 17 19 * 29 30 31 30 8 9 Kentucky 6.8 6.8 29 33 ** 28 28 30 32 * 37 36 19 16 * Louisiana 10.3 8.8 ** 25 31 ** 23 25 * 31 35 ** 36 40 ** 12 16 ** Maine 5.7 5.7 24 27 * 20 20 27 29 * 28 30 * 14 13 Maryland 8.5 7.2 * 22 24 * 17 16 27 28 29 32 * 9 9 Massachusetts 4.8 5.1 21 23 * 16 16 22 23 30 31 8 9 Michigan 7.6 7.6 24 29 ** 20 23 * 28 32 ** 31 33 * 9 11 * Minnesota 4.6 4.6 18 20 * 16 19 * 25 25 23 27 ** 7 7 Mississippi 9.9 10.1 28 32 ** 24 24 34 36 * 44 40 ** 18 18 Missouri 7.5 7.1 24 29 ** 23 24 28 30 * 31 28 * 10 12 * Montana 4.6 6.2 ** 25 28 * 19 20 23 24 26 29 * 9 10 Nebraska 6.5 5.4 * 20 24 ** 21 20 27 28 31 29 * 8 7 Nevada 6.2 5.8 26 30 ** 22 18 ** 26 27 34 33 12 11 New Hampshire 5.6 4.9 * 23 24 19 17 * 26 27 29 26 * 10 10 New Jersey 5.6 5.2 23 23 17 17 24 24 31 25 ** 10 9 New Mexico 6.5 5.3 * 27 31 ** 21 19 * 26 29 * 33 33 9 9 New York 6.2 5.4 * 26 26 18 16 * 25 23 * 33 32 10 10 North Carolina 8.7 7.9 * 26 27 22 21 30 31 34 31 * 13 13 North Dakota 5.9 6.3 17 19 * 20 20 27 29 * 26 36 ** 7 7 Ohio 7.5 7.7 25 27 * 23 23 29 30 33 31 * 11 13 * Oklahoma 7.9 7.9 29 31 * 26 23 * 30 33 * 30 34 ** 15 14 Oregon 5.5 4.9 27 33 ** 17 18 27 28 24 26 * 9 10 Pennsylvania 7.3 7.1 23 26 * 21 21 28 29 30 26 ** 11 11 Rhode Island 5.4 5.9 24 26 * 17 17 22 26 ** 30 28 * 8 9 South Carolina 9.3 7.0 ** 24 28 ** 22 22 30 33 * 34 39 ** 14 15 South Dakota 7.9 6.7 * 20 22 * 20 21 27 27 28 27 8 9 Tennessee 8.6 8.0 25 30 ** 22 24 * 32 33 36 34 * 12 18 ** Texas 6.3 6.0 27 27 18 18 28 30 * 32 37 ** 7 8 Utah 5.2 5.3 20 23 * 12 10 * 22 24 * 23 22 5 5 Vermont 4.4 6.2 ** 21 22 17 16 22 23 27 25 * 10 11 Virginia 7.4 7.1 21 26 ** 18 19 24 27 * 31 30 8 10 * Washington 5.5 4.9 26 29 * 17 17 26 27 30 26 ** 8 8 West Virginia 7.6 7.7 31 35 ** 26 28 * 32 35 * 36 34 * 20 23 * Wisconsin 5.9 6.0 19 23 ** 20 20 25 30 ** 28 29 10 11 Wyoming 8.8 6.0 ** 22 22 23 22 25 25 26 27 11 11 Change 16 41 23 28 32 11 States Improved 14 0 13 3 18 1 States Worsened 2 41 10 25 14 10 Notes: * denotes a change of at least 0.5 standard deviation; ** denotes a change of 1.0 standard deviation or more. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org49 Appendix Exhibit A12. Mortality Amenable to Health Care by Race, Deaths per 100,000 Population, 2004–05 and 2009–10 Total White Black Change 2014 Change 2014 Change 2014 2004–05 2009–10 in rate rank 2004–05 2009–10 in rate rank 2004–05 2009–10 in rate rank United States 96 86 –10 — 86 78 –8 — 183 159 –24 — Alabama 117 114 –3 47 97 96 –1 44 189 180 –9 30 Alaska 77 74 –3 16 67 64 –3 11 112 — — — Arizona 88 74 –14 16 85 71 –14 21 146 126 –20 7 Arkansas 121 116 –5 48 108 104 –4 49 219 202 –17 36 California 86 75 –11 20 84 73 –11 24 175 150 –25 15 Colorado 72 62 –10 4 71 61 –10 5 128 111 –17 3 Connecticut 77 67 –10 9 72 62 –10 7 137 123 –14 6 Delaware 97 90 –7 31 87 78 –9 31 148 146 –2 13 District of Columbia 158 119 –39 49 56 46 –10 1 220 170 –50 24 Florida 91 83 –8 28 81 74 –7 26 167 145 –22 10 Georgia 114 103 –11 42 91 83 –8 37 190 163 –27 20 Hawaii 80 78 –2 23 73 62 –11 7 68 — — — Idaho 74 67 –7 9 74 66 –8 16 — — — — Illinois 101 90 –11 31 86 78 –8 31 209 180 –29 30 Indiana 101 93 –8 34 95 87 –8 40 186 167 –19 22 Iowa 79 74 –5 16 78 72 –6 23 144 — — — Kansas 85 78 –7 23 80 74 –6 26 170 145 –25 10 Kentucky 110 106 –4 43 106 102 –4 47 176 175 –1 28 Louisiana 137 123 –14 50 106 98 –8 45 221 190 –31 34 Maine 78 67 –11 9 77 67 –10 17 — — — — Maryland 107 95 –12 37 87 76 –11 29 172 149 –23 14 Massachusetts 78 65 –13 6 77 64 –13 11 125 98 –27 1 Michigan 102 90 –12 31 87 77 –10 30 208 189 –19 33 Minnesota 64 57 –7 1 61 54 –7 2 129 119 –10 5 Mississippi 142 136 –6 51 108 104 –4 49 221 204 –17 37 Missouri 103 95 –8 37 94 87 –7 40 196 172 –24 26 Montana 73 73 0 15 70 69 –1 18 — — — — Nebraska 72 67 –5 9 69 65 –4 13 167 145 –22 10 Nevada 112 97 –15 40 109 95 –14 43 191 156 –35 18 New Hampshire 73 60 –13 3 73 60 –13 4 86 — — — New Jersey 90 77 –13 22 81 70 –11 20 169 141 –28 9 New Mexico 83 81 –2 25 82 79 –3 34 108 114 6 4 New York 93 82 –11 26 85 75 –10 28 149 129 –20 8 North Carolina 108 95 –13 37 89 81 –8 36 186 157 –29 19 North Dakota 73 75 2 20 70 69 –1 18 — — — — Ohio 106 94 –12 35 96 85 –11 39 197 169 –28 23 Oklahoma 115 112 –3 46 109 103 –6 48 196 193 –3 35 Oregon 75 65 –10 6 75 65 –10 13 135 — — — Pennsylvania 99 86 –13 30 90 78 –12 31 193 173 –20 27 Rhode Island 86 74 –12 16 84 71 –13 21 141 — — — South Carolina 115 102 –13 41 92 83 –9 37 188 163 –25 20 South Dakota 81 71 –10 13 74 63 –11 9 — — — — Tennessee 118 110 –8 45 104 98 –6 45 213 187 –26 32 Texas 100 94 –6 35 92 87 –5 40 194 170 –24 24 Utah 64 62 –2 4 64 61 –3 5 86 — — — Vermont 68 58 –10 2 69 58 –11 3 — — — — Virginia 96 85 –11 29 81 73 –8 24 176 151 –25 16 Washington 74 65 –9 6 73 63 –10 9 119 108 –11 2 West Virginia 112 107 –5 44 111 106 –5 51 171 152 –19 17 Wisconsin 78 71 –7 13 72 65 –7 13 180 178 –2 29 Wyoming 75 82 7 26 75 80 5 35 — — — — Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 50 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix Exhibit A13. Summary Changes in Equity Dimension Gap widenend and Gap narrowed and Number of states nonwhite group nonwhite group Change in Race/Ethnicty with data worsened improved national average Uninsured ages 0–64 51 16 28 Improved Adults who went without care because of cost in the 51 23 12 No change past year At-risk adults who did not visit a doctor for a routine 50 28 19 Worsened checkup in the past two years Adults without a usual source of carec 51 20 22 No change Older adults without recommended preventive carec 46 15 21 Improved Children without a medical homec 51 14 25 No change Children without a medical and dental preventive care —a —a —a —a visit in the past yeara,c Mortality amenable to health care 37 1 30 Improved Infant mortality, deaths per 1,000 live births 48 15 28 Improved Adults with poor health-related quality of life 51 22 12 No change Gap widenend and Gap narrowed and Number of states low-income group low-income group Change in Income with data worsened improved national average Uninsured ages 0–64 51 12 25 Improved Adults who went without care because of cost in the 51 10 11 No change past year At-risk adults who did not visit a doctor for a routine 51 8 33 No change checkup in the past two years Adults without a usual source of carec 51 4 33 Improved Older adults without recommended preventive carec 51 23 14 No change Children without a medical homec 51 19 17 No change Children without a medical and dental preventive care —a —a —a —a visit in the past yeara,c Elderly patients who received a high-risk prescription —b —b —b —b drugb Adults with poor health-related quality of life 51 33 6 Worsened Notes: (a) Data not comparable across years. (b) Historical data not available. (c) Directionality of these indicators is reversed from how reported elsewhere in the report. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org51 Appendix Exhibit A14. Summary of Equity Indicator Rankings by State Total Race 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 7 16 44% 3 9 33% 4 7 57% Alaska 7 15 47% 3 8 38% 4 7 57% Arizona 6 16 38% 3 9 33% 3 7 43% Arkansas 6 16 38% 5 9 56% 1 7 14% California 7 16 44% 4 9 44% 3 7 43% Colorado 8 16 50% 5 9 56% 3 7 43% Connecticut 7 16 44% 4 9 44% 3 7 43% Delaware 8 16 50% 5 9 56% 3 7 43% District of Columbia 11 16 69% 4 9 44% 7 7 100% Florida 6 16 38% 4 9 44% 2 7 29% Georgia 5 16 31% 3 9 33% 2 7 29% Hawaii 5 15 33% 3 8 38% 2 7 29% Idaho 4 15 27% 2 8 25% 2 7 29% Illinois 9 16 56% 6 9 67% 3 7 43% Indiana 2 16 13% 2 9 22% 0 7 0% Iowa 7 14 50% 3 7 43% 4 7 57% Kansas 3 16 19% 2 9 22% 1 7 14% Kentucky 4 16 25% 2 9 22% 2 7 29% Louisiana 10 16 63% 7 9 78% 3 7 43% Maine 4 13 31% 2 6 33% 2 7 29% Maryland 11 16 69% 6 9 67% 5 7 71% Massachusetts 11 16 69% 6 9 67% 5 7 71% Michigan 6 16 38% 4 9 44% 2 7 29% Minnesota 4 15 27% 1 8 13% 3 7 43% Mississippi 8 16 50% 6 9 67% 2 7 29% Missouri 6 16 38% 4 9 44% 2 7 29% Montana 2 15 13% 0 8 0% 2 7 29% Nebraska 7 16 44% 4 9 44% 3 7 43% Nevada 8 16 50% 5 9 56% 3 7 43% New Hampshire 6 14 43% 3 7 43% 3 7 43% New Jersey 6 16 38% 4 9 44% 2 7 29% New Mexico 5 16 31% 2 9 22% 3 7 43% New York 9 16 56% 5 9 56% 4 7 57% North Carolina 7 16 44% 4 9 44% 3 7 43% North Dakota 5 13 38% 4 6 67% 1 7 14% Ohio 7 16 44% 5 9 56% 2 7 29% Oklahoma 9 16 56% 5 9 56% 4 7 57% Oregon 4 15 27% 2 8 25% 2 7 29% Pennsylvania 6 16 38% 4 9 44% 2 7 29% Rhode Island 3 15 20% 2 8 25% 1 7 14% South Carolina 8 16 50% 6 9 67% 2 7 29% South Dakota 5 14 36% 2 7 29% 3 7 43% Tennessee 4 16 25% 4 9 44% 0 7 0% Texas 8 16 50% 5 9 56% 3 7 43% Utah 9 15 60% 5 8 63% 4 7 57% Vermont 9 14 64% 4 7 57% 5 7 71% Virginia 12 16 75% 7 9 78% 5 7 71% Washington 7 16 44% 5 9 56% 2 7 29% West Virginia 6 16 38% 4 9 44% 2 7 29% Wisconsin 6 16 38% 4 9 44% 2 7 29% Wyoming 6 15 40% 3 8 38% 3 7 43% Note: See state profiles online for state equity dimension rankings. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. 52 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 Appendix Exhibit B1. State Scorecard Data Years and Databases Indicator Past year Current year Database Access and Affordability Dimension Summary 1 Adults ages 19–64 uninsured 2007–08 2011–12 CPS ASEC 2 Children ages 0–18 uninsured 2007–08 2011–12 CPS ASEC 3 Adults who went without care because of cost in past year 2007 2012 BRFSS 4 Individuals under age 65 with high out-of-pocket medical costs relative to their annual household income —a 2011–12 CPS ASEC 5 At-risk adults without a routine doctor visit in past two years 2007 2012 BRFSS 6 Adults without a dental visit in past year 2006 2012 BRFSS Prevention and Treatment Dimension Summary 7 Adults with a usual source of care 2007 2012 BRFSS 8 Adults ages 50 and older who received recommended screening and preventive care 2006 2012 BRFSS 9 Children with a medical home 2007 2011/12 NSCH 10 Children with a medical and dental preventive care visit in the past year —a 2011/12 NSCH Children with emotional, behavioral, or developmental problems who received needed mental health 11 2007 2011/12 NSCH care in the past year 12 Children ages 19–35 months who received all recommended doses of seven key vaccines 2009 2012 NIS 13 Medicare beneficiaries who received at least one drug that should be avoided in the elderly 2007 2011 5% Medicare enrolled in Part D Medicare beneficiaries with dementia, hip/pelvic fracture, or chronic renal failure who received a 14 2007 2011 5% Medicare enrolled in Part D prescription drug that is contraindicated for that condition Medicare fee-for-service patients whose health provider always listens, explains, shows respect, and CAHPS (via AHRQ National 15 2007 2013 spends enough time with them Healthcare Quality Report) Risk-adjusted 30-day mortality among Medicare beneficiaries hospitalized for heart attack, heart failure, 07/2005– 07/2008– 16 CMS Hospital Compare or pneumonia 06/2008 06/2011 17 Hospitalized patients given information about what to do during their recovery at home 2007 2011 HCAHPS (via CMS Hospital Compare) Hospitalized patients who reported hospital staff always managed pain well, responded when needed 18 2007 2011 HCAHPS (via CMS Hospital Compare) help to get to bathroom or pressed call button, and explained medicines and side effects 04/2012– OASIS (via CMS Home Health 19 Home health patients who get better at walking or moving around —a 03/2013 Compare) 04/2012– OASIS (via CMS Home Health 20 Home health patients whose wounds improved or healed after an operation —a 03/2013 Compare) 07/2012– MDS (via CMS Nursing Home 21 High-risk nursing home residents with pressure sores —a 03/2013 Compare) 07/2012– MDS (via CMS Nursing Home 22 Long-stay nursing home residents with an antipsychotic medication —a 03/2013 Compare) Avoidable Hospital Use and Cost Dimension Summary HCUP (via AHRQ National Healthcare 23 Hospital admissions for pediatric asthma, per 100,000 children 2004 2010 Quality Report) Hospital admissions for ambulatory care–sensitive conditions: CCW (via CMS Geographic Variation 24 2008 2012 Medicare beneficiaries ages 65–74 and age 75 and older Public Use File) CCW (via CMS Geographic Variation 25 Medicare 30-day hospital readmissions, rate per 1,000 beneficiaries 2008 2012 Public Use File) 26 Short-stay nursing home residents readmitted within 30 days of hospital discharge to nursing home 2006 2010 MedPAR, MDS 27 Long-stay nursing home residents hospitalized within a six-month period 2006 2010 MedPAR, MDS Medicare Claims (via CMS Home 28 Home health patients also enrolled in Medicare with a hospital admission —a 2012 Health Compare) 29 Potentially avoidable emergency department visits among Medicare beneficiaries, per 1,000 beneficiaries —a 2011 5% Medicare SAF 30 Total single premium per enrolled employee at private-sector establishments that offer health insurance 2008 2012 MEPS CCW (via CMS Geographic Variation 31 Total Medicare (Parts A & B) reimbursements per enrollee 2008 2012 Public Use File) Healthy Lives Dimension Summary CDC NVSS: Mortality Restricted 32 Mortality amenable to health care, deaths per 100,000 population 2004–05 2009–10 Use File 33 Years of potential life lost before age 75 2005 2010 CDC NVSS: WISQARS 34 Breast cancer deaths per 100,000 female population 2005 2010 CDC NVSS: WONDER 35 Colorectal cancer deaths per 100,000 population 2005 2010 CDC NVSS: WONDER 36 Suicide deaths per 100,000 population 2005 2010 CDC NVSS: WONDER 37 Infant mortality, deaths per 1,000 live births 2004 2009 CDC NVSS: WONDER Adults ages 18–64 who report fair/poor health or activity limitations because of physical, mental, 38 2007 2012 BRFSS or emotional problems 39 Adults who smoke 2007 2012 BRFSS 40 Adults ages 18–64 who are obese (BMI >= 30) 2007 2012 BRFSS 41 Children ages 10–17 who are overweight or obese (BMI >= 85th percentile) 2007 2011/12 NSCH Percent of adults ages 18–64 who have lost six or more teeth because of tooth decay, infection, 42 2006 2012 BRFSS or gum disease Note: (a) Previous data not available or its definition is not comperable over time. Source: Commonwealth Fund Scorecard on State Health System Performance, 2014. www.commonwealthfund.org53 Appendix B2. Scorecard Indicator Descriptions and Source Notes 1. Percent of adults ages 19-64 uninsured: Authors’ analysis of Annual (as defined) during the past 12 months. For more information, see www. Social and Economic Supplement to the Current Population Survey (CPS childhealthdata.org. Authors’ analysis of 2007 and 2011/12 National ASEC) using the CPS Table Creator online at http://www.census.gov/cps/ Survey of Children’s Health (CAHMI, NSCH 2007, 2011/12). data/cpstablecreator.html (U.S. Census Bureau, CPS ASES, 2007, 2008, 12. Percent of children ages 19-35 months who received all 2012, 2013). recommended doses of seven key vaccines: Percent of children ages 2. Percent of children ages 0-18 uninsured: Authors’ analysis of Annual 19-35 months who received at least 4 doses of diphtheria, tetanus, and Social and Economic Supplement to the Current Population Survey (CPS accellular pertussis (DTaP/DT/DTP) vaccine; at least 3 doses of poliovirus ASEC) using the CPS Table Creator online at http://www.census.gov/cps/ vaccine; at least 1 dose of measles-containing vaccine (including mumps- data/cpstablecreator.html (U.S. Census Bureau, CPS ASES, 2007, 2008, rubella(MMR) vaccine); full series of Haemophilus influenza type b (Hib) 2012, 2013). vaccine (3 or 4 doses depending on product type); at least 3 doses of hepatitis B vaccine (HepB); at least 1 dose of varicella vaccine, and at 3. Percent of adults who went without care because of cost in the least 4 doses of pneumococcal conjugate vaccine (PCV). This indicator past year: Authors’ analysis of 2007 and 2012 Behavioral Risk Factor is modified from that reported in the 2009 State Scorecard, reflecting Surveillance System (NCCDPHP, BRFSS 2007, 2012). changes in vaccination standards. Data from the 2009 and 2012 National 4. Percent of individuals under age 65 with high out-of-pocket Immunization Survey (NCHS, NIS 2009, 2012). medical spending relative to their annual income: This indicator is 13. Percent of Medicare beneficiaries received at least one drug that new to the State Scorecard, 2014 edition. Out-of-pocket medical expenses should be avoided in the elderly: This indicator is new to the State equaled 10 percent or more of income, or five percent or more of income Scorecard, 2014 edition. Percent of Medicare beneficiaries age 65 and older if low-income (under 200% of Federal Poverty Level), not including health received at least one drug from a list of 13 classes of high-risk prescriptions insurance premiums. C. Solis-Roman, Robert F. Wagner School of Public that should be avoided by the elderly. Y. Zhang and S.H. Baik, University Service, New York University, analysis of 2012, 2013 Current Population of Pittsburgh, analysis of 2007, 2010, and 2011 5% sample of Medicare Survey, Annual Social and Economic Supplement (U.S. Census Bureau, CPS beneficiaries enrolled in stand-alone Medicare Part D plans. (2010 data ASES 2012, 2013). used for stratification by income for equity analysis.) 5. At-risk adults without a routine doctor visit in past two years: 14. Percent of Medicare beneficiaries with dementia, hip/pelvic Percent of adults age 50 or older, or in fair or poor health, or ever told they fracture, or chronic renal failure received prescription in an have diabetes or pre-diabetes, acute myocardial infarction, heart disease, ambulatory care setting that is contraindicated for that condition: stroke, or asthma who did not visit a doctor for a routine checkup in the This indicator is new to the State Scorecard, 2014 edition. Y. Zhang and past two years. Authors’ analysis of 2007 and 2012 Behavioral Risk Factor S.H. Baik, University of Pittsburgh, analysis of 2007, 2011 5% sample of Surveillance System (NCCDPHP, BRFSS 2007, 2012). Medicare beneficiaries enrolled in stand-alone Medicare Part D plans. 6. Percent of adults without a dental visit in the past year: This 15. Medicare fee-for-service patients whose health provider always indicator is new to the State Scorecard, 2014 edition. Percent of adults who listens, explains, shows respect, and spends enough time with them: did not visit a dentist, or dental clinic within the past year. Authors’ analysis Percent of Medicare fee-for-service patients who had a doctor’s office or of 2006 and 2012 Behavioral Risk Factor Surveillance System (NCCDPHP, clinic visit in the last 12 months whose health providers always listened BRFSS 2006, 2012). carefully, explained things clearly, respected what they had to say, and 7. Percent of adults with a usual source of care: Percent of adults spent enough time with them. Data from National Consumer Assessment ages 18 and older who have one (or more) person they think of as of Healthcare Providers and Systems (CAHPS) Benchmarking Database their personal healthcare provider. Authors’ analysis of 2007 and 2012 (AHRQ, CAHPS n.d.), reported in National Healthcare Quality Report (AHRQ Behavioral Risk Factor Surveillance System (NCCDPHP, BRFSS 2007, 2012). 2007, 2013). 8. Percent of adults age 50 and older received recommended 16. Risk-adjusted 30-day mortality among Medicare patients screening and preventive care: Percent of adults age 50 and older who hospitalized for heart attack, heart failure or pneumonia: This have received: sigmoidoscopy or colonoscopy in the last ten years or a indicator is new to the State Scorecard, 2014 edition. Risk-standardized, fecal occult blood test in the last two years; a mammogram in the last two all-cause 30-day mortality rates for Medicare patients age 65 and older years (women only); a pap smear in the last three years (women only); hospitalized with a principal diagnosis of heart attack, heart failure or and a flu shot in the past year and a pneumonia vaccine ever (age 65 and pneumonia between July 2005 and June 2008 and July 2008 and June older only). Authors’ analysis of 2006 and 2012 Behavioral Risk Factor 2011. All-cause mortality is defined as death from any cause within 30 Surveillance System (NCCDPHP, BRFSS 2006, 2012). days after the index admission, regardless of whether the patient dies 9. Percent of children with a medical home: Percent of children who while still in the hospital or after discharge. Authors’ analysis of Medicare have a personal doctor or nurse, have a usual source for sick and well enrollment and claims data retrieved September 2013 from CMS Hospital care, receive family-centered care, have no problems getting needed Compare (DHHS n.d.). referrals, and receive effective care coordination when needed. For more 17. Percent of hospitalized patients who were given information information, see www.childhealthdata.org. Authors’ analysis of 2007 about what to do during their recovery at home: This indicator is and 2011/12 National Survey of Children’s Health (CAHMI, NSCH 2007, modified from that reported in the 2009 State Scorecard, expanding from 2011/12). discharges among heart failure patients to include all discharges. Authors’ 10. Percent of children with a medical and dental preventive care analysis of Hospital Consumer Assessment of Healthcare Providers and visit in the past year: Percent of children 0-17 with a preventive medical Systems Survey data (HCAHPS n.d.) retrieved September 2013 from CMS visit and, if ages 1-17, a preventive dental visit in the past year. Current Hospital Compare (DHHS n.d.). data (2011-12) and past data (2007), reported in the 2009 State Scorecard, 18. Percent of patients reported hospital staff always managed pain are not comparable because of changes in survey design. For more well, responded when needed help to get to bathroom or pressed information, see www.childhealthdata.org. Authors’ analysis of 2011/12 call button, and explained medicines and side effects: This indicator National Survey of Children’s Health (CAHMI, NSCH 2011/12). is new to the State Scorecard, 2014 edition. Authors’ analysis of Hospital 11. Percent of children with emotional, behavioral, or developmental Consumer Assessment of Healthcare Providers and Systems Survey data problems who received needed mental health care in the past (HCAHPS n.d.) retrieved September 2013 from CMS Hospital Compare year: Percent of children ages 2-17 who had any kind of emotional, (DHHS n.d.). developmental, or behavioral problem that required treatment or 19. Home health patients who get better at walking or moving counseling and who received treatment from a mental health professional around: Percent of all home health episodes in which a person improved 54 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 at walking or moving around compared to a prior assessment. Episodes admitted nursing home residents (never been in a facility before) who are for which the patient, at start or resumption of care, was able to ambulate re-hospitalized within 30 days of being discharged to nursing home.V. independently are excluded. Current data (4/2012-3/2013) and past Mor, Brown University, analysis of 2010 Medicare enrollment data and data (2007), reported in the 2009 State Scorecard, are not comparable Medicare Provider and Analysis Review (CMS, MEDPAR 2010). because of changes in the underlying clinical assessment instrument and 27. Percent of long-stay nursing home residents hospitalized within data collection processes. Authors’ analysis of April 2012 -March 2013 a six-month period: Percent of long-stay residents (residing in a nursing Outcome and Assessment Information Set (CMS, OASIS n.d.) data retrieved home for at least 90 consecutive days) who were ever hospitalized within September 2013 from CMS Home Health Compare (DHHS n.d.). six months of baseline assessment. V. Mor, Brown University, analysis of 20. Home health patients whose wounds improved or healed after 2010 Medicare enrollment data, Medicare Provider and Analysis Review an operation: This indicator is new to the State Scorecard, 2014 edition. File (CMS, MEDPAR 2010). Percent of all home health episodes in which a person’s surgical wound is 28. Home health patients also enrolled in Medicare with a hospital more fully healed compared to a prior assessment. Episodes for which the admission: Percent of acute care hospitalization for home health episodes patient, at start or resumption of care, did not have any surgical wounds or that occurred in 2012. Current data (2012) and past data (2007) are not had only a surgical wound that was unobservable are excluded. Authors’ comparable because of changes in the underlying data source and data analysis of April 2012-March 2013 Outcome and Assessment Information collection processes. Authors’ analysis data from CMS Medicare claims Set (CMS, OASIS n.d.) data retrieved September 2013 from CMS Home data retrieved September 2013 from CMS Home Health Compare (DHHS Health Compare (DHHS n.d.). n.d.). 21. High-risk nursing home residents with pressure sores: Percent of 29. Potentially avoidable emergency department visits among long-stay nursing home residents impaired in bed mobility or transfer, Medicare beneficiaries, per 1,000 beneficiaries: This indicator is new comatose, or malnourished who have pressure sores (Stages 1-4) on target to the State Scorecard, 2014 edition. Potentially avoidable emergency assessment. Current data (7/2012-3/2013) and past data (2007), reported department visits were those that, based on diagnoses recorded during in the 2009 State Scorecard, are not comparable because of changes in the the visit and the health care service the patient received, were considered underlying clinical assessment instrument and data collection processes. to be either non-emergent (care was not needed within 12 hours), or Authors’ analysis of April 2012 -March 2013 Minimum Data Set (CMS, MDS emergent (care needed within 12 hours) but that could have been treated n.d.) retrieved September 2013 from CMS Nursing Home Compare ( DHHS safely and effectively in a primary care setting. This definition excludes n.d.). any emergency department visit that resulted in an admission, as well 22. Long-stay nursing home residents with an antipsychotic as emergency department visits where the level of care provided in the medication: This indicator is new to the State Scorecard, 2014 edition. ED was clinically indicated. J. Zheng, Harvard University, analysis of 2011 The percent of long-stay nursing home residents that received an Medicare Enrollment and Claims Data 5% sample, Chronic Conditions antipsychotic medication, excluding residents with Schizophrenia, Warehouse (CMS, CCW 2011), using the New York University Center for Tourette’s syndrome, and Huntington’s disease. Authors’ analysis of CMS Health and Public Service Research emergency department algorithm Minimum Data Set (CMS, MDS n.d.) retrieved September 2013 from CMS developed by John Billings. Nursing Home Compare. 30. Total single premium per enrolled employee at private-sector 23. Hospital admissions for pediatric asthma, per 100,000 children establishments that offer health insurance: Data from Medical (ages 2-17): Excludes patients with cystic fibrosis or anomalies of the Expenditure Panel Survey–Insurance Component (AHRQ, MEPS-IC 2008, respiratory system, and transfers from other institutions. Authors’ analysis 2012). of 2004 and 2010 Healthcare Cost and Utilization Project State Inpatient 31. Total Medicare (Parts A&B) reimbursements per enrollee: Total Databases; not all states participate in HCUP. Estimates for total U.S. are Medicare fee-for-service reimbursements include payments for both Part from the Nationwide Inpatient Sample (AHRQ, HCUPT-SID 2004, 2010). A and Part B but exclude Part D (prescription drug costs) and extra CMS Reported in the National Healthcare Quality Report (AHRQ 2004, 2010). payments for graduate medical education and for treating low-income 24. Hospital admissions for ambulatory care-sensitive conditions, per patients. Reimbursements reflect only the age 65 and older Medicare 1,000 beneficiaries: fee-for-service population. Authors’ analysis of 2008 and 2012 Chronic Conditions Warehouse (CCW) data, retrieved from the December 2013 Medicare beneficiaries ages 65-74: CMS Geographic Variation Public Use File (CMS, Office of Information Medicare beneficiaries ages 75 and older: Products and Analytics (OPIDA) 2013). Hospital admissions of fee-for-service Medicare beneficiaries age 65-74 32. Mortality amenable to health care, deaths per 100,000 and 75 and older for one of the following eight ambulatory care–sensitive population: Number of deaths before age 75 per 100,000 population that (ACS) conditions: long-term diabetes complications, lower extremity resulted from causes considered at least partially treatable or preventable amputation among patients with diabetes, asthma or chronic obstructive with timely and appropriate medical care (see list), as described in Nolte pulmonary disease, hypertension, congestive heart failure, dehydration, and McKee (Nolte and McKee, BMJ 2003). Authors’ analysis of mortality bacterial pneumonia, and urinary tract infection. This indicator is modified data from CDC restricted-use Multiple Cause-of-Death file and U.S. Census from that reported in the 2009 State Scorecard, which included 11 ACS Bureau population data, 2004-2005 and 2009-2010 (NCHS, MCD n.d.). conditions in the composite measures. Authors’ analysis of 2008 and 2012 Causes of death Age Chronic Conditions Warehouse (CCW) data, retrieved from the December Intestinal infections................................................................................................ 0–14 2013 CMS Geographic Variation Public Use File (CMS, Office of Information Tuberculosis.............................................................................................................. 0–74 Products and Analytics (OPIDA) 2013). Other infections (diphtheria, tetanus, septicaemia, poliomyelitis)............... 0–74 25. Medicare 30-day hospital readmissions, rate per 1,000 Whooping cough.................................................................................................... 0–14 beneficiaries: All hospital admissions among Medicare beneficiaries age Measles....................................................................................................................... 1–14 65 and older that were readmitted within 30 days of an acute hospital Malignant neoplasm of colon and rectum.................................................... 0–74 stay for any cause. A correction was made to account for likely transfers Malignant neoplasm of skin................................................................................ 0–74 between hospitals. This indicator is modified from that reported in Malignant neoplasm of breast........................................................................... 0–74 the 2009 State Scorecard, which included readmissions for only select Malignant neoplasm of cervix uteri................................................................. 0–74 index admission diagnoses. Authors’ analysis of 2008 and 2012 Chronic Malignant neoplasm of cervix uteri and body of uterus.......................... 0–44 Conditions Warehouse (CCW) data, retrieved from the December 2013 Malignant neoplasm of testis............................................................................. 0–74 CMS Geographic Variation Public Use File (CMS, Office of Information Hodgkin’s disease................................................................................................... 0–74 Products and Analytics (OPIDA) 2013). Leukemia.................................................................................................................... 0–44 26. Percent of short-stay nursing home residents readmitted within Diseases of the thyroid.......................................................................................... 0–74 30 days of hospital discharge to the nursing home: Percent of newly Diabetes mellitus.................................................................................................... 0–49 Epilepsy...................................................................................................................... 0–74 www.commonwealthfund.org55 Chronic rheumatic heart disease...................................................................... 0–74 36. Suicide deaths per 100,000 population: Authors’ analysis of NVSS– Hypertensive disease............................................................................................. 0–74 Mortality Data 2005 and 2010 (NCHS NVSS), retrieved using the CDC Cerebrovascular disease....................................................................................... 0–74 Wide-ranging OnLine Data for Epidemiologic Research (WONDER). (NVSS All respiratory diseases (excluding pneumonia and influenza)............. 1–14 2005 and 2010). Influenza..................................................................................................................... 0–74 37. Infant mortality, deaths per 1,000 live births: Authors’ analysis of Pneumonia................................................................................................................ 0–74 National Vital Statistics System–Linked Birth and Infant Death Data, 2004 Peptic ulcer................................................................................................................ 0–74 and 2009 (NCHS, NVSS, 2004, 2009), retrieved using the CDC Wide-ranging Appendicitis.............................................................................................................. 0–74 OnLine Data for Epidemiologic Research (WONDER).(NVSS 2004 and 2009). Abdominal hernia................................................................................................... 0–74 Cholelithiasis and cholecystitis.......................................................................... 0–74 38. Percent of adults ages 18–64 report being in fair or poor health, Nephritis and nephrosis....................................................................................... 0–74 or who have activity limitations because of physical, mental, or Benign prostatic hyperplasia.............................................................................. 0–74 emotional problems: This indicator is new to the State Scorecard, Maternal death.............................................................................................................All 2014 edition. Authors’ analysis of 2007 and 2012 Behavioral Risk Factor Congenital cardiovascular anomalies............................................................. 0–74 Surveillance System (NCCDPHP, BRFSS 2007, 2012). Perinatal deaths, all causes, excluding stillbirths.............................................All 39. Percent of adults who smoke: Percent of adults age 18 and older Misadventures to patients during surgical and medical care......................All who ever smoked 100+ cigarettes (five packs) and currently smoke every Ischaemic heart disease: 50% of mortality rates included....................... 0–74 day or some days. Authors’ analysis of 2007 and 2012 Behavioral Risk Factor Surveillance System (NCCDPHP, BRFSS 2007, 2012). 33. Years of potential life lost before age 75: This indicator is new to the State Scorecard, 2014 edition. Robert Wood Johnson Foundation analysis 40. Percent of adults ages 18-64 who are obese (Body Mass Index of National Vital Statistics System Mortality Data, 2005 and 2010, using [BMI] ≥ 30): Authors’ analysis of 2007 and 2012 Behavioral Risk Factor the Centers for Disease Control and Prevention (CDC) National Center Surveillance System (NCCDPHP, BRFSS 2007, 2012). for Injury Prevention and Control Web-based Injury Statistics Query and 41. Children (ages 10–17) who are overweight or obese (Body Mass Reporting System (WISQARS). Retrieved July 2013 from Robert Wood Index [BMI] ≥ 85th percentile): Overweight is defined as an age- and Johnson Foundation National DataHub. (NVSS 2005 and 2010). gender-specific body mass index (BMI-forage) between the 85th and 94th 34. Breast cancer deaths per 100,000 female population: Authors’ percentile of the CDC growth charts. Obese is defined as a BMI-for-age analysis of NVSS–Mortality Data, 2005 and 2010 (NCHS, NVSS n.d.), at or above the 95th percentile. BMI was calculated based on parent- retrieved using the CDC Wide-ranging OnLine Data for Epidemiologic reported height and weight. For more information, see www.nschdata. Research (WONDER). (NVSS 2005 and 2010) org. Data from the National Survey of Children’s Health, assembled by the Child and Adolescent Health Measurement Initiative (CAHMI, NCHS 2007, 35. Colorectal cancer deaths per 100,000 population: Authors’ analysis 2011/2012). of NVSS–Mortality Data, 2005 and 2010 (NCHS, NVSS n.d.), retrieved using the CDC Wide-ranging OnLine Data for Epidemiologic Research 42. Percent of adults ages 18–64 who have lost 6 or more teeth due to (WONDER). (NVSS 2005 and 2010) tooth decay, infection, or gum disease: This indicator is new to the State Scorecard, 2014 edition. Authors’ analysis of 2006 and 2012 Behavioral Risk Factor Surveillance System (NCCDPHP, BRFSS 2006, 2012). 56 Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 One East 75th Street The 1150 17th Street NW Suite 600 New York, NY 10021 COMMONWEALTH Washington, DC 20036 Tel 212.606.3800 FUND Tel 202.292.6700 www.commonwealthfund.org