AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance 2017 EDITION David C. Radley Douglas McCarthy Susan L. Hayes Senior Scientist Senior Research Director Senior Research Associate The Commonwealth Fund The Commonwealth Fund The Commonwealth Fund MARCH 2017 MARCH 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition David C. Radley, Douglas McCarthy, and Susan L. Hayes ABSTRACT ISSUE: States are a locus of policy and leadership for health system performance. GOAL: To compare and evaluate trends in health care access, quality, avoidable hospital use and costs, health outcomes, and health system equity across all 50 states and the District of Columbia. METHODS: States are ranked on 44 performance measures using recently available data. KEY FINDINGS: Nearly all states improved more than they worsened between 2013 and 2015. The biggest gains were in health insurance coverage and the ability to access care when needed, with states that had expanded their Medicaid programs under the Affordable Care Act experiencing the most improvement. There were also widespread state improvements on key indicators of treatment quality and patient safety; hospital patient readmissions also fell in many states. However, premature deaths crept up in almost two-thirds of states, reversing a long period of decline. Wide variations in performance across states persisted, as did disparities experienced by vulnerable populations within states. CONCLUSION: If every state achieved the performance of top-ranked states, their residents and the country as a whole would realize dramatic gains in health care access, quality, efficiency, and health outcomes. AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 3 HIGHLIGHTS FROM THE SCORECARD The 2017 edition of the Commonwealth Fund Scorecard on State Health System Performance finds that nearly all state health systems improved on a broad array of health indicators between 2013 and 2015. During this period, which coincides with implementation of the Affordable Care Act’s major coverage expansions, uninsured rates dropped and more people were able to access needed care, particularly those in states that expanded their Medicaid programs. On a less positive note, between 2011–12 and 2013–14, premature death rates rose slightly following a long decline. The Scorecard points to a constant give-and-take in efforts to improve health and health care, reminding us that there is still more to be done. Overall State Health System Performance Scorecard Ranking, 2017 Overall performance, 2017 Top quartile (13 states) Second quartile (11 states + D.C.) Third quartile (13 states) Bottom quartile (13 states) commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 4 Vermont was the top-ranked state overall in readmitted to the hospital. The most pervasive this year’s Scorecard, followed by Minnesota, improvements in health system performance Hawaii, Rhode Island, and Massachusetts occurred where policymakers and health (Exhibit 1). California, Colorado, Kentucky, system leaders created programs, incentives, New York, and Washington made the biggest or collaborations to ensure access to care and jumps in ranking, with New York moving into improve the quality and efficiency of care. For the top-performing group for the first time. example, the decline in hospital readmissions Kentucky also stood out for having improved accelerated after the federal government began on more measures than any other state. levying financial penalties on hospitals that had high rates of readmissions and created Using the most recent data available, the hospital improvement innovation networks to Scorecard ranks states on more than 40 help spread best practices.1 measures of health system performance in five broad areas: health care access, quality, Still, wide performance variation across states, avoidable hospital use and costs, health as well as persistent disparities by race and outcomes, and health care equity. In reviewing economic status within states, are clear signals the data, four key themes emerged: that our nation is a long way from offering everyone an equal opportunity for a long, • There was more improvement than decline healthy, and productive life. Looking forward, in states’ health system performance. it is likely that states will be challenged to provide leadership on health policy as • States that expanded Medicaid saw greater the federal government considers a new gains in access to care. relationship with states in public financing • Premature death rates crept up in almost of health care. To improve the health of their two-thirds of states. residents, states must find creative ways of addressing the causes of rising mortality rates • Across all measures, there was a threefold while also working to strengthen primary and variation in performance, on average, preventive care. between top- and bottom-performing states, signifying opportunities for (See Scorecard Methods and Appendix for a improvement. complete description of how the Scorecard was developed and detail on indicators and By 2015, fewer people in every state lacked measurement periods.) health insurance. Across the country, more patients benefited from better quality of care in doctors’ offices and hospitals, and Medicare beneficiaries were less frequently commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 5 Exhibit 1. State Scorecard Summary of Health System Performance Across Dimensions Overall performance Top quartile Second quartile t t s s Co Co Third quartile & & t t en en se se y y Bottom quartile lit lit lU lU tm tm bi bi ita ita ea ea da da sp sp Tr Tr or or s s Ho Ho & & ve ve Aff Aff 2017 Revised n n Li Li e e tio tio & & bl bl y y Scorecard Ranking Baseline Ranking en en ss ss da da th th ty ty ce ce ev ev oi oi al al ui ui He He Av Av Eq Eq Ac Ac Pr Pr 1 Vermont 1 1 1 1 1 1 Minnesota 1 1 1 1 1 2 Minnesota 1 1 1 1 1 1 Vermont 1 1 2 1 1 3 Hawaii 1 2 1 1 1 3 Hawaii 1 2 1 1 1 4 Rhode Island 1 1 2 1 1 4 Massachusetts 1 1 3 1 1 5 Massachusetts 1 1 4 1 1 5 New Hampshire 1 1 2 1 1 6 Colorado 2 2 1 1 1 6 Iowa 1 1 1 2 1 6 Iowa 1 1 2 2 1 7 Connecticut 1 1 3 1 1 8 Connecticut 1 1 4 1 1 7 Rhode Island 1 1 2 1 2 8 New Hampshire 1 1 3 2 1 9 Maine 2 1 2 2 1 10 Washington 2 2 1 1 1 9 Nebraska 2 2 1 2 1 11 Wisconsin 2 1 2 2 3 11 Colorado 3 1 1 1 2 12 Maryland 1 2 3 2 2 12 Utah 3 3 1 1 1 12 New York 2 2 3 1 1 12 Wisconsin 2 1 2 2 2 14 California 2 3 2 1 1 14 Delaware 1 2 2 3 1 15 Delaware 1 1 3 3 2 14 Maryland 1 2 3 2 2 15 Maine 2 1 2 3 2 16 North Dakota 2 2 2 2 2 15 Nebraska 3 2 2 2 2 16 Pennsylvania 1 1 3 3 2 15 South Dakota 3 1 1 3 2 16 South Dakota 2 1 2 3 2 15 Utah 4 3 1 1 2 16 Washington 3 3 1 1 2 20 District of Columbia 1 2 3 3 2 20 Idaho 4 3 1 2 2 20 North Dakota 3 2 2 2 2 20 New York 1 3 4 2 1 22 New Jersey 2 2 4 1 2 22 District of Columbia 1 2 4 2 2 22 Oregon 3 3 1 2 2 22 New Jersey 2 2 4 1 2 22 Pennsylvania 1 1 3 3 3 24 Oregon 3 3 1 2 3 25 Virginia 2 2 2 2 2 24 Virginia 2 2 3 2 3 26 Idaho 4 3 1 2 3 26 California 3 4 2 1 2 27 Illinois 2 2 4 2 2 27 Kansas 2 2 3 3 3 28 Kansas 3 2 3 3 3 28 Wyoming 3 3 2 2 3 29 Michigan 2 2 4 3 3 29 Illinois 2 2 4 2 3 29 Montana 3 3 1 3 3 30 Michigan 2 2 3 4 3 29 New Mexico 3 4 1 3 2 30 Montana 4 3 1 2 3 32 Arizona 4 4 1 2 2 30 New Mexico 4 4 1 3 2 32 Ohio 2 2 3 3 3 30 Ohio 2 2 3 4 3 32 Wyoming 3 3 2 2 4 34 Alaska 3 4 2 3 3 35 North Carolina 3 2 2 3 3 34 Missouri 2 2 3 4 4 36 Alaska 4 4 1 3 3 36 Arizona 4 4 1 2 3 37 Missouri 3 3 3 4 3 36 North Carolina 3 2 3 3 4 38 West Virginia 2 2 4 4 3 38 Tennessee 3 3 4 4 3 39 Florida 4 4 4 2 3 39 Alabama 3 3 4 4 3 39 Kentucky 2 3 4 4 4 39 Florida 4 4 3 2 4 41 Georgia 4 4 2 4 4 41 Nevada 4 4 2 3 4 41 South Carolina 3 4 2 4 4 41 South Carolina 4 3 2 4 4 41 Texas 4 4 3 2 3 41 Texas 4 4 3 2 3 44 Indiana 3 3 3 4 4 41 West Virginia 3 2 4 4 4 44 Tennessee 3 3 3 4 4 45 Georgia 4 4 3 3 4 46 Nevada 4 4 2 3 4 45 Indiana 3 4 3 4 4 47 Alabama 3 4 4 4 4 47 Kentucky 3 3 4 4 4 48 Arkansas 4 4 4 4 4 48 Louisiana 4 4 4 4 4 49 Louisiana 4 4 4 4 4 49 Arkansas 4 4 3 4 4 49 Oklahoma 4 3 4 4 4 50 Oklahoma 4 4 4 4 4 51 Mississippi 4 4 4 4 4 51 Mississippi 4 4 4 4 4 Note: States highlighted in green expanded their Medicaid programs under the Affordable Care Act as of Jan. 1 2015. The 2017 rankings are based on the most current year of data available, generally reflecting 2014 or 2015; the revised baseline rankings generally reflect the 2012 or 2013 data year. Note several measures have changed since our December 2015 Scorecard was published, and the ranks reported here are not strictly comparable to that report. See Scorecard Methods and Appendix and for more detail on Scorecard metrics and ranking methods. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 6 MORE IMPROVEMENT THAN Exhibit 2. Number of Indicators Improved or Worsened, by State DECLINE IN STATES’ HEALTH improved Number of indicators worsened Number of indicators SYSTEM PERFORMANCE 4 Kentucky 21 Health system performance improved 2 Oklahoma 19 2 New York 17 in more instances than it worsened 6 District of Columbia 17 from 2013 to 2015,2 reversing states’ 1 Illinois 17 1 New Jersey 16 performance trajectory coming out 2 Tennessee 16 of the recession of 2007–09 (Exhibit 2 Arkansas 16 6 Louisiana 16 2).3 All but four states (Alaska, Hawaii, 4 Mississippi 16 New Hampshire, Oregon) improved 2 Washington 15 4 South Dakota 15 on at least twice as many indicators 4 North Dakota 15 as they worsened on. Kentucky and 2 Pennsylvania 15 Oklahoma were “most improved”— 4 Arizona 15 4 Indiana 15 meeting or exceeding the Scorecard’s 5 14 Rhode Island threshold for improvement on 21 2 Iowa 14 3 Colorado 14 and 19 indicators respectively. All 3 California 14 states and the District of Columbia 5 Virginia 14 4 Montana 14 worsened on at least one indicator. 4 Wyoming 14 2 Maryland 13 4 Delaware 13 Widespread and Unprecedented 5 Kansas 13 Gains in Access 1 Michigan 13 5 Missouri 13 Health System improvement over 3 West Virginia 13 time is not a given. As documented 4 Vermont 12 3 Wisconsin 12 previously in our Scorecard series, 5 Idaho 12 worsening or stagnating performance 1 North Carolina 12 4 Florida 12 was pervasive across states in the 3 Texas 12 first decade of the 2000s, particularly 4 Georgia 12 5 12 on indicators of health care access, Alabama 3 Minnesota 11 as the number of uninsured adults 3 Connecticut 11 continued to rise and more people 9 New Hampshire 11 6 Oregon 11 skipped needed care.4 1 Ohio 11 4 South Carolina 11 The implementation of the 5 Massachusetts 10 Affordable Care Act’s major coverage 5 Nevada 10 3 Utah 9 expansions in 2014 led to a sharp 4 New Mexico 9 reversal in these access trends. In this 10 Alaska 9 4 Nebraska 8 year’s Scorecard, these expansions 4 Maine 8 were associated with improvements 7 Hawaii 6 on at least three indicators of access Notes: States highlighted in green expanded their Medicaid programs under the Affordable Care Act as of Jan. to care in the majority of states. 1 2015. Based on trends for 39 of 44 total indicators; trend data are not available for all indicators. Bar length equals the total number of indicators with any improvement or worsening with an absolute value greater than Between 2013 and 2015, nearly all 0.5 standard deviations of the state distribution. Lighter portion of bars represents the number of indicators with states and the District of Columbia a change of 0.5-0.9 standard deviations between baseline and current time periods, darker portions represent indicators with 1.0 or greater standard deviation change. Ambulatory care–sensitive conditions among Medicare met the Scorecard’s threshold for beneficiaries from two age groups are considered a single indicator in tallies of improvement. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 7 improvement of at least a three-percentage-point decline Improvements Aided by Targeted Reforms in the uninsured rate for adults ages 19 to 64. More than States made progress in other areas that were the half of states improved—at least a two-point reduction— target of concerted efforts to improve health system in their uninsured rate for children. Three-quarters of performance. For example, the Hospital Readmission states and the District of Columbia had a drop of at least Reduction Program, established by the Affordable Care two percentage points in the share of adults (age 18 and Act, requires the Centers for Medicare and Medicaid older) who reported not going to the doctor when they Services (CMS) to reduce reimbursement to hospitals needed to because of costs (Exhibit 3). that have higher-than-expected readmissions of Research has shown that people with health insurance Medicare beneficiaries discharged from the hospital coverage are more likely than those without to have a usual in the previous 30 days after being treated for certain source of care and to have had a recent health care visit.5 In conditions. The payment penalties began in October the first two years of the coverage expansions, about a third 2012; between 2012 and 2014, 33 states and the District of states, along with the District of Columbia, saw jumps of Columbia substantially lowered their all-cause in the share of adults with a usual doctor or health care readmission rate among Medicare beneficiaries. The provider and in the share of “at risk” adults with a routine largest reductions of 12 to 13 readmissions per 1,000 check-up in the past two years (Exhibit 3). At-risk adults Medicare beneficiaries were in Kentucky, Illinois, and are those age 50 or older, as well as younger adults with a D.C., all of which had the highest rates at the outset chronic illness or in fair or poor health. (Exhibit 4). Read more about health care access across states. Exhibit 3 Widespread Gainsin Access to Health Care, 2013–20152013–2015 Exhibit 3. Widespread Gains in Access to Health Care, Number of states that: Improved Had little or no change Worsened 17 17 28 2 39 3 49 12 23 34 31 Adults Children Adults who Adults with At-risk adults ages 19–64 ages 0–18 went without a usual source with a routine uninsured uninsured care because of care doctor visit in of costs in the past two years past year Notes: For this exhibit, we count the District of Columbia as a state. “Improved” or “worsened” refers to a change between 2013 and 2015 of at least 0.5 standard deviations. “Little or no change” includes states with changes of less than 0.5 standard deviations as well as states with no change or without sufficient data to assess change. “Adults with a usual source of care” is an indicator in the Scorecard’s Prevention and Treatment dimension; it is included here because having a regular health care provider is associated with better access to care. Data: Uninsured: U.S. Census Bureau, 2013 and 2015 1-Year American Community Surveys. Public Use Micro Sample (ACS PUMS). Cost Barriers, Doctor Visit, and Usual Source of Care: 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS). commonwealthfund.org March 2017 Source: D. C. Radley, D. McCarthy, and S. L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017. AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 8 Exhibit 4 States with Highest Hospital Readmission Rates in 2012 Saw Exhibit 4.Improvements by Readmission Rates in 2012 Saw Large Improvements by 2014 Large States with Highest Hospital 2014 Rate of 30-day hospital readmissions per 1,000 Medicare beneficiaries 2012 2014 60 50 U.S. average, 2012 40 34 per 1,000 30 U.S. average, 2014 20 27 per 1,000 10 0 Hawaii Oregon Idaho Utah Minnesota Colorado New Mexico Arizona Washington California* Montana Nevada Connecticut* Wisconsin* Rhode Island Alaska* Maine Pennsylvania* South Dakota* Vermont* Wyoming Georgia* Iowa* Nebraska* South Carolina* Florida New Hampshire Ohio* Texas* North Carolina* North Dakota* New York* Kansas* Missouri* Tennessee* Alabama* Delaware Indiana* Louisiana* Oklahoma* Massachusetts* Virginia* Arkansas* Michigan* West Virginia* New Jersey* District of Columbia* Mississippi* Maryland* Kentucky* Illinois* Notes: States are arranged in order (lowest to highest) of their readmission rate in 2012. * Denotes states with at least -0.5 standard deviation change (at least 5 fewer readmissions per 1,000) between 2012 and 2014. Data: Medicare claims via Feb. 2016 CMS Geographic Variation Public Use File. Exhibit 5 Widespread Patient Safety and S.Commonwealth Fund, March 2017. the Commonwealth Fund Scorecard on State Health Source: D. C. Radley, D. McCarthy, Gains Aiming Doctors’ Offices and Hospitals System Performance 2017 Edition, The L. Hayes, in Higher: Results from Exhibit 5. Widespread Patient Safety Gains in Doctors’ Offices and Hospitals Number of states that: Improved Had little or no change Worsened 21 5 46 9 21 Elderly Medicare beneficiaries who received a Central line-associated bloodstream infections (CLABSI), high-risk prescription drug, 2012 to 2014 standardized infection ratio, 2013 to 2014 Notes: For this exhibit we count the District of Columbia as a state. “Improved” or “worsened” refers to a change between the baseline and current time periods of at least 0.5 standard deviations. “Little or no change” includes states with changes of less than 0.5 standard deviations as well as states with no change or without sufficient data to assess change. Data: High-Risk Prescription Drug Use: 2012 and 2014 Medicare Part D 5% Sample. Analysis by Y. Zhang, University of Pittsburgh. CLABSI: Centers for Disease Control and Prevention, 2013 and 2014 National and State Healthcare-Associated Infections Progress Report. commonwealthfund.org March 2017 Source: D. C. Radley, D. McCarthy, and S. L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017. AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 9 Public policies and private partnerships have also States Expanding Medicaid Saw Greater Gains in Access focused on improving patient safety across care settings. The Scorecard finds that states that accepted federal funding In recent years, there has been growing uptake of to expand their Medicaid programs under the Affordable electronic prescribing and associated clinical decision Care Act outperformed states that did not expand Medicaid.7 support, aggressively encouraged by the federal Expansion states typically ranked higher than nonexpansion government through incentives for implementing states before and after the law’s coverage expansions electronic health records. 6 This change may explain in (Exhibit 1), but they also saw the greatest gains in health part why Medicare beneficiaries in 46 states were less care access between 2013 and 2015. For example, states that achieved double-digit reductions in their uninsured rate likely to be prescribed a high-risk medicine in 2014 than for working-age adults between 2013 to 2015—Arkansas, in 2012. In hospitals, progress is being made in reducing California, Kentucky, Nevada, New Mexico, Oregon, Rhode costly and potentially deadly central line-associated Island, Washington, and West Virginia—all had expanded bloodstream infections (CLABSIs), as strategies for Medicaid as soon as federal resources became available reducing their incidence are refined and implemented in 2014 (Exhibit 6). Over the two-year period, Kentucky, more widely. For the first time, the Scorecard can track followed by Arkansas and Oregon, experienced the biggest state-level average CLABSI rates; it found notable declines drops in the share of adults 18 and older who reported relative to a national benchmark between 2013 and 2014 forgoing needed care because of costs (7 points, 5 points, and in 20 states and the District of Columbia (Exhibit 5). 5 points, respectively) (Appendix C2). Exhibit 6 Exhibit 6.Thatthat Expanded Medicaid Saw Greatest Reductions in Rates of Uninsured Working- States States Expanded Medicaid Saw Greatest Reductions in Rates AgeUninsured Working-Age Adults of Adults Percent 2013 2015 35 States that expanded Medicaid States that had not expanded Medicaid as of January 1, 2015 as of January 1, 2015 30 25 20 15 10 5 0 New Mexico North Carolina Nevada New Hampshire Arizona California Washington Colorado Ohio New York North Dakota South Carolina Florida Georgia Louisiana Oklahoma Utah Wisconsin Arkansas Oregon West Virginia New Jersey Rhode Island Michigan Delaware Maryland Pennsylvania Iowa Alaska Idaho Connecticut Alabama Wyoming South Dakota Kentucky Illinois Minnesota Vermont Massachusetts Texas Montana Tennessee Indiana District of Columbia Kansas Virginia Maine Nebraska Hawaii Mississippi Missouri Notes: States are arranged in rank order based on their uninsured rate in 2013. Alaska, Indiana, Louisiana, and Montana expanded their Medicaid programs after Jan. 1, 2015. Data: U.S. Census Bureau, 2013 and 2015 One-Year American Community Surveys. Public Use Micro Sample (ACS PUMS). Source: D. C. Radley, D. McCarthy, and S. L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 10 Low-income people fared relatively better in Medicaid PREMATURE DEATH RATES CREPT UP IN expansion states than their counterparts did in ALMOST TWO-THIRDS OF STATES nonexpansion states. For example, the proportion of Recent headlines point to a troubling reality in the U.S.: low-income working-age adults who were uninsured Americans can expect to live a shorter life than they did shrank more, on average, in states that had expanded a decade ago.9,10 This is primarily the result of increased Medicaid than in states that did not (Exhibit 7). In deaths from heart disease and other chronic conditions. addition, Medicaid-expanding states saw a greater But to a lesser extent, the trend is also attributable to reduction in the share of low-income adults going without what Princeton economist Anne Case has called “deaths care because of costs or lacking a usual source of care. of despair”—including fatalities from opioid and alcohol The fact that nonexpansion states did not keep pace abuse.11 Findings from the Scorecard reinforce these with expansion states in improving access and equity is discouraging trends. reflected in the overall Scorecard rankings. Of the four The Scorecard measures mortality by tracking premature nonexpansion states that were ranked in the top quartile of overall performance in the 2013 baseline period, only death rates overall as well as by separately measuring Wisconsin repeated its top quartile performance in the deaths from two high-profile cancers, suicide, and infant latest ranking8 Maine, Nebraska, and Utah all fell and mortality. It is important to note that mortality data dropped from the top-performance quartile. reported in the Scorecard extend only through 2014, the latest year available, and include deaths that occurred The five states that had the most dramatic upward shifts before insurance coverage expansions. in overall rankings were Medicaid-expansion states: California moved up 12 places; Kentucky and New York Taking a closer look at deaths before age 75 that might each moved up eight places; Washington jumped six have been prevented with accessible and effective Exhibitand Colorado rose five places. spots; 7 health care, we find a decade-long decrease in mortality States That Expanded Medicaid Experienced Greater Improvement in Exhibit 7. States That Expanded Medicaid Experienced Greater Improvement in Health Care Access Health Care Access Amongand 2015 Among Low-Income Populations, 2013 Low-Income Populations, 2013 to 2015 Average percentage-point change, 2013 to 2015 Adults who went without Adults without a regular Uninsured adults care because of costs health care providera -2.3 -2.7 -1.0 -5.5 -8.9 -14.1 Medicaid-expansion states Nonexpansion states (as of January 1, 2015) Notes: Alaska, Indiana, Louisiana, and Montana expanded their Medicaid programs after Jan. 1, 2015. a Adults with a usual source of care is reported elsewhere in the Scorecard, such that a higher value is favorable; for this exhibit, the share of “adults without a regular health care provider” is reported. Low income refers to household income <200% of the federal poverty level. Data: Uninsured (ages 19–64): U.S. Census Bureau, 2013 and 2015 One-Year American Community Surveys. Public Use Micro Sample (ACS PUMS). Cost Barriers and Usual Source of Care (age 18 and older): 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS). commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 11 reversed course in recent years as the rate rose slightly between 2011–12 CALIFORNIA JUMPS AHEAD and 2013–14 (Exhibit 8). There is also a California improved the most of any state in the 2017 overall rankings, significant racial disparity in premature climbing up 12 spots, from 26th place in the baseline to 14th. death rates. Over the last decade, African Americans experienced a greater California met—and in some cases far exceeded—the Scorecard’s reduction in mortality amenable to threshold for improvement on 14 of the 39 indicators for which we health care than did other racial or had trend data. The most dramatic shifts were in uninsured rates. ethnic groups. However, that reduction Between 2013, the year before the Affordable Care Act’s major coverage expansions took effect, and 2015, California sliced its did not eliminate disparities for African uninsured rates for working-age adults and for children in half (from Americans, who in all states (where 24% to 12%, and 8% to 4%, respectively). data were available) remained more likely than whites or Hispanics to die Between 2013 and 2015, the share of adults in California reporting before age 75 from treatable conditions that they went without needed care because of costs dropped by 4 in 2013–14. In 10 states and the District percentage points, the share of adult Californians with a usual source of Columbia, there was a more than of care jumped 6 percentage points (from 71% to 77%), and the twofold disparity in rates between share of at-risk adults without a recent routine doctor’s visit improved by 3 percentage points. blacks and both whites or Hispanics (Exhibit 9). How did the nation’s most populous state do it? “We were ‘all in’ in terms of the ACA, and it coincided with a strong economy here in While these overarching trends in California. I’m sure the two worked off of one another,” says Chris mortality are concerning, there is Perrone, director of Improving Access at the California Health some good news. Deaths from breast Care Foundation. Six months after the passage of the ACA in 2010, and colon cancer fell between 2012 California became the first state to enact legislation to create its and 2014, as did adult smoking rates, health insurance marketplace, Covered California, regarded as one a key risk factor for heart disease and of the most successful in the country. In the first three years, the lung cancer. The positive health effects average purchase price for plans on Covered California was less likely to accrue from reduced rates of than the average offer price, suggesting enrollees chose lower-cost smoking may be outweighed, however, plans and prompting the authors of a research study to conclude: by the negative health effects of obesity “Covered California demonstrates—straight out of Economics (Appendix F2).12 101—if consumers have easy-to-understand, transparent information without being overwhelmed with too many choices, The health care coverage and access they will buy lower-premium products available on their tier.”14,15 gains noted earlier promote more regular access to primary care, which California also expanded eligibility for its Medicaid program under the has been linked to earlier disease ACA as soon as federal resources became available in January 2014. It also devoted significant resources to outreach and enrollment detection and greater adherence to efforts for both marketplace and Medicaid managed care plans. treatment regimens, among other benefits.13 But strengthening primary The state improved on indicators that spanned all age groups and care is not enough. The social and other care settings, including a substantial decrease in 30-day hospital determinants of health must also be readmissions among Medicare beneficiaries, which at the outset was addressed to produce hoped-for gains in already lower than in many other states.16 health outcomes. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 12 Exhibit 8 Premature Death Rates from Treatable Conditions Rose Slightly Exhibit 8. Premature Death Rates from Treatable Conditions Rose Slightly Among Whites and Hispanics Following Decade-Longand Hispanics Following Decade-Long Decline Among Whites Decline Mortality amenable to health care: deaths per 100,000 population Cumulative 200 −5.8% Annual % change decline: −5.1% 180 −3.7% 2004–2014 −8.1% −1.3% 160 −22% Black 140 120 −5.3% 100 −4.7% −5.4% −3.1% −5.2% 0.2% −17% Total −4.4% 80 −5.2% −2.9% −3.7% 0.8% −15% White −6.5% −1.4% 60 −9.8% 0.3% −21% Hispanic 40 20 0 2003–04 2005–06 2007–08 2009–10 2011–12 2013–14 Data: 2003–2014 National Vital Statistics System (NVSS) Mortality All-County Micro Data Files. Exhibit 9 In Every State, African Americans More Likely Than Whites to Exhibit 9. In Every State, African Americans More Likely Than Whites to Die Early from Treatable Die Early from Treatable Conditions, 2013–14 Conditions, 2013–14 Source: D. C. Radley, D. McCarthy, and S. L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017. Mortality amenable to health care: deaths per 100,000 population White Black Hispanic 200 150 U.S. average, all races= 84.1 per 100 100,000 50 0 Massachusetts Rhode Island Alaska Maine Connecticut Minnesota Washington Hawaii Oregon Colorado Arizona New Mexico Delaware Maryland Nebraska Florida New York United States Virginia New Jersey California West Virginia Iowa Utah North Carolina Nevada Georgia Kentucky Kansas South Carolina Indiana Pennsylvania Ohio Missouri Texas Alabama Wisconsin Illinois Tennessee Michigan District of Columbia Louisiana Oklahoma Arkansas Mississippi Idaho Wyoming Vermont New Hampshire South Dakota North Dakota Montana Notes: Data for black race not available for Idaho, Montana, New Hampshire, North Dakota, South Dakota, Vermont, or Wyoming. Data for Hispanic ethnicity not available for Maine, Montana, New Hampshire, North Dakota, South Dakota, Vermont, or West Virginia. States arranged in rank order based on black mortality. Data: 2013 and 2014 National Vital Statistics System (NVSS) Mortality All-County Micro Data Files. Source: D. C. Radley, D. McCarthy, and S. L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 13 A CLOSER LOOK AT HOSPITAL MORTALITY The Scorecard measures deaths within 30 days of hospital discharge among Medicare beneficiaries treated for four common conditions for which evidence-based treatment can promote better outcomes: heart attack, stroke, Hospital Mortality is Up congestive heart failure, and pneumonia. Hospital 30-day mortality rates rose in nearly all states between the two measurement periods reported in the Scorecard, driving the national average from 13.2 percent to 14.5 percent. (CMS reports hospital mortality over a three-year timeframe.) The increase in this rate, which represents a reversal in the previous improvement trend, appears to be driven by a sharp uptick in mortality among pneumonia patients. Average 30-day mortality among patients 2010–2013 2012–2015 discharged for heart attack, stroke, congestive heart failure, or pneumonia (%) Average 30-day hospital mortality by condition (%) 16.3 14.9 15.3 14.9 14.5 14.1 13.2 11.9 12.1 11.9 Total Heart attack Stroke Congestive heart failure Pneumonia Data: CMS Hospital Compare, 2014 and 2016 4th Quarter, National-Level Summary Estimates. THREEFOLD VARIATIONSPerformanceD. McCarthy, and S.Commonwealth Fund,low incomes and for members of racialState Health ACROSS Edition, The L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on and ethnic Source: D. C. Radley, System 2017 with March 2017. MEASURES BETWEEN TOP- AND BOTTOM- minority groups in most—but not all—states compared PERFORMING STATES to national norms. For example, the share of low-income The Scorecard is a stark reminder that where you live adults who skipped needed care because of cost was 21 affects your ability to access high-quality health care and percentage points higher than the overall U.S. average your prospects for a healthy life. On average, performance in Texas (34% vs. 13%), whereas it was four points lower than the overall U.S. average in Vermont (9%) (Exhibit in the highest-ranked state on a given indicator was three 10). Similarly, rates of forgone care due to cost for racial times better than in the lowest-ranked state, with even and ethnic minority populations are much higher than wider variation for some indicators. For example, there the overall U.S. average in the worst-performing states: was an almost sixfold difference in uninsured rates among Oklahoma had the highest rate for blacks and South working-age adults (23% in Texas vs. 4% in Massachusetts) Carolina had the highest rate for Hispanics. Despite and a fourfold difference in rates of readmissions to the these disparities, recent trends are promising. As state hospital among Medicare beneficiaries (10 per 1,000 in performance improved overall for many indicators, state Hawaii vs. at least 40 per 1,000 in the District of Columbia, equity gaps also more often narrowed than widened for Maryland, Mississippi, and New Jersey). the majority of equity indicators tracked by the Scorecard. The Scorecard also finds continuing disparities for those (Appendix G2). commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 14 Exhibit 10 Exhibit 10. Wide State Variations byby Income and Race/Ethnicity inWho Went Wide State Variations Income and Race/Ethnicity in Percentage of Adults Percentage Without Care Because of Cost, 2015 of Adults Who Went Without Care Because of Cost, 2015 By Income By Race/Ethnicity Less than 200% 400% federal poverty White Black Hispanic federal poverty level level or higher TX 34% SC 31% OK 26% 24% 22% Overall MS U.S. average 17% 13% 16% VT NV KY 10% 9% ND 9% DC AK 9% 6% 3% 6% 6% National average Top state Bottom state National average Top state Bottom state Data: 2015 Behavioral Risk Factor Surveillance System (BRFSS). Source: D. C. Radley, D. McCarthy, and S. L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017. ASSESSING STATE HEALTH SYSTEM EQUITY Health care inequities result from disparities in access to and availability of care (e.g., the number of people who have insurance or who visit a dentist regularly), health outcomes (e.g., mortality), and risks (e.g., the number of people who are obese or are smokers) between various groups. The Scorecard’s Equity dimension looks at two vulnerable populations: low-income people and those who belong to racial and ethnic minorities. A state’s performance is based on gaps in equity—that is, the difference between the state’s vulnerable population and the U.S. average for any given indicator. Improvement is defined as an improvement in the state’s vulnerable group rate and a narrowing in the performance gap between the vulnerable group and the U.S. average. Across the nation, health care equity remains an unfulfilled goal. The health insurance expansions brought about by the Affordable Care Act (assuming they are not reversed) offer the opportunity to close these gaps. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 15 IMPLICATIONS generally achieve better outcomes.17 Promoting All states have the opportunity to improve, including an adequate primary care workforce, especially in those at the top. On certain indicators, states that ranked underserved areas, may require collaborating with other lower overall performed better than those at the top of payers to support the development of effective primary the overall rankings, which suggests that states can learn care medical homes, among other actions. from each other. If every state achieved the performance States have unequal economic circumstances and resources of the top-ranked state on each Scorecard indicator, to support improvement. The gains brought about by their residents and the country as a whole would realize Medicaid expansion and marketplace subsidies in places dramatic gains in access, quality, efficiency, and health like Kentucky highlight the role the federal government outcomes (Exhibit 11). can play in helping to equalize opportunity. Efforts in California and elsewhere show how states can leverage States can take various steps to promote improvement. federal reforms to achieve their own goals. These gains may Examples include using value-based purchasing, be challenged by the proposed repeal and replacement establishing rules to ensure equitable access and of the Affordable Care Act, which could lead to widening competitive insurance markets, setting strategies for inequality between and within states. health information technology and exchange, and supporting public health and community-based With the future uncertain, it will be more important than organizations that address social determinants of health. ever to track state health system performance as states Health systems with a stronger primary care orientation assume greater responsibility for the future of health policy. Exhibit 11 National Gains IfIfAll States Achieved of Performance of Performance Exhibit 11. National Gains All States Achieved Top Rates* Top Rates* 20 million more adults and children insured, beyond those who already gained coverage through the ACA 14 million fewer adults skipping care because of its cost 26 million more adults with a usual source of care 12 million more adults receiving recommended cancer screenings 513,000 more young children receiving all recommended vaccines 1 million fewer Medicare beneficiaries receiving a high-risk prescription drug 124,000 fewer hospital readmissions among Medicare beneficiaries age 65 and older 1.4 million fewer emergency room visits for nonemergency care or conditions treatable with primary care 90,000 fewer deaths before age 75 from treatable diseases Note: * Performance benchmarks set at the level achieved by the top-performing state with available data for this indicator. Source: D. C. Radley, D. McCarthy, and S. L. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 16 SCORECARD METHODS The Commonwealth Fund Scorecard on State Health System Performance, 2017, evaluates 44 health care performance indicators grouped into four dimensions: • 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 (18 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; of these, hospital admissions for ambulatory care–sensitive conditions were 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 estimates of per-person spending for Medicare beneficiaries and the cost of employer-sponsored insurance. • Healthy Lives (11 indicators): includes measures of premature death and health risk behaviors. EQUITY DIMENSION. The Scorecard evaluates starting with the 2015 State Scorecard; hence, differences in performance associated with the 2017 equity rankings are not strictly patients’ income level (19 indicators) or race comparable to those published before the 2015 or ethnicity (16 indicators) that span the State Scorecard. other four dimensions of performance. The data available for some equity indicators, The following principles guided the such as childhood vaccinations, may development of the Scorecard: represent a different time point from that used in the corresponding main Scorecard PERFORMANCE METRICS. The 44 performance indicator. For each state, performance on metrics selected for this report span the each equity indicator as it pertains to low- health care system and represent important income populations (under 200% of the dimensions of care. Where possible, indicators federal poverty level) and racial or ethnic align with those used in previous state minority groups (black or other race or scorecards. Over time, several indicators Hispanic ethnicity) is compared with the have been dropped, either because all states national average. The resulting difference in improved to the point where no meaningful performance is the “equity gap,” which forms variations existed (e.g., hospital quality the basis of our state rankings for this domain. process-of-care measures) or the data to To support more comprehensive assessment construct the measures were no longer of disparities, we expanded the number of available. Several new indicators were added indicators evaluated in the equity dimension to the Scorecard series since 2014, including commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 17 measures of premature death (years of potential To assess change over time in the Equity life lost), out-of-pocket spending on medical dimension, we counted how often the equity care relative to income, CLABSI, per-enrollee gap narrowed across indicators for each state spending among adults with employer- during the period measured by the Scorecard. sponsored insurance, and potentially avoidable We considered improvement to have occurred emergency department use. in an equity indicator only if the equity gap narrowed and health care for the state’s most MEASURING CHANGE OVER TIME. We were vulnerable group improved. able to construct a time series for 39 of 44 indicators. Four Scorecard indicators derived DATA SOURCES. Indicators were drawn from from the National Survey of Children’s Health publicly available data sources, including could not be updated, because the survey is government-sponsored surveys, registries, conducted only every four years. publicly reported quality indicators, vital statistics, mortality data, and administrative There were generally one to two years between databases. The most current data available an indicator’s baseline and current-year data were used in this report whenever possible. observation, though the start and end points Appendix H provides detail on the data sources depended on data availability. We chose this and time frames. short time horizon to capture the immediate effects of changes relative to the policy and SCORING AND RANKING METHODS. The delivery system environment, such as recent scoring method follows previous state coverage expansions under the Affordable Care scorecards. States are first ranked from best Act and other reforms. In this 2017 Scorecard, to worst on each of the 44 performance we compare state rankings between the current indicators. We averaged rankings for indicators year and baseline periods; the baseline rankings within each dimension to determine a state’s generally reflect the period preceding the state dimension rank and then averaged dimension rankings reported in our 2015 Scorecard.18 rankings to determine overall ranking. This approach gives each dimension equal weight, We considered a change in an indicator’s value and within dimensions weights indicators between the historical and current-year data equally. As in previous scorecards, if historical points to be meaningful if it was at least one data were not available for a particular half (0.5) of a standard deviation larger than the indicator in the baseline period, the most indictor’s combined distribution over the two current year of data available was used as a time points—a common approach in social substitute. This ensures that ranks in each science research. period were based on the same number of indicators and were as similar as possible. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 18 NOTES B. Zuckerman, S. H. Sheingold, E. J. Orav et al., 1 R. July 2014); A. Porterfield, K. Engelbert, and A. Coustasse, “Readmissions, Observation, and the Hospital “Electronic Prescribing: Improving the Efficiency and Readmissions Reduction Program,” New England Journal Accuracy of Prescribing in the Ambulatory Care Setting,” of Medicine, April 21, 2016, 374(16):1543–51; R. A. Berenson Perspectives in Health Information Management, Spring and T. Rice, “Beyond Measurement and Reward: Methods 2014: 1–13; B. Clyne, M. C. Bradley, C. Hughes et al., of Motivating Quality Improvement and Accountability,” “Electronic Prescribing and Other Forms of Technology to Health Services Research, Dec. 2015, 50(Suppl. 2):2155–86; Reduce Inappropriate Medication Use and Polypharmacy Centers for Medicare and Medicaid Services, Partnership in Older People: A Review of Current Evidence,” Clinics in for Patients, https://partnershipforpatients.cms.gov. Geriatric Medicine, May 2012 28(2):301–22. The Scorecard evaluates change for 39 of the 44 2 7 The Scorecard sets January 1, 2015, as the cutoff date for performance indicators for which data were available which a state would be considered an expansion state, over time. Performance measures are constructed from because this date best aligns with the health insurance the most recently available data, generally reflecting the coverage data used in this analysis from the American two-year period ending in 2014 or 2015, though this does Community Survey. Alaska, Indiana, Louisiana, and vary somewhat by indicator. We identified instances Montana implemented Medicaid expansion between of improvement or worsening that can be considered February 2015 and July 2016 but are considered meaningful if there was at least 0.5 standard deviation nonexpanding states in this Scorecard. change between the indicators’ observed rates in the two periods. Refer to the Appendix for more detail on 8 Wisconsin is unique compared to other nonexpansion performance measures included here. states in that it has higher Medicaid eligibility thresholds; for example, it provides coverage to childless adults with C. Radley, D. McCarthy, J. A. Lippa, S. L. Hayes, and C. 3 D. incomes up to 100 percent of the federal poverty level. Schoen, Aiming Higher: Results from a Scorecard on State Health System Performance, 2014 (The Commonwealth 9 Q. Xu, S. L. Murphy, K. D. Kochanek et al., Mortality in J. Fund, May 2014). the United States, 2015, NCHS data brief, no. 267 (National Center for Health Statistics, 2016). 4 D. C. Radley, D. McCarthy, J. A. Lippa, S. L. Hayes, and C. Schoen, Aiming Higher: Results from a Scorecard on State 10 . Stein, “Life Expectancy in U.S. Drops for First Time R Health System Performance, 2014 (The Commonwealth in Decades, Report Finds,” National Public Radio, Fund, May 2014); D. McCarthy, S. K. H. How, C. Schoen, J. Dec. 8, 2016, http://www.npr.org/sections/health- C. Cantor, D. Belloff, Aiming Higher Results from a State shots/2016/12/08/504667607/life-expectancy-in- Scorecard on Health System Performance, 2009 (The u-s-drops-for-first-time-in-decades-report-finds; Commonwealth Fund, Oct. 2009). and J. Bacon “Dying Younger: U.S. Life Expectancy ‘A Real Problem’,”USA Today, Dec. 8 2016, http:// 5 Centers for Disease Control/National Center for Health www.usatoday.com/story/news/nation/2016/12/08/ Statistics, “Health Insurance and Access to Care,” National has-us-life-expectancy-maxed-out-first-decline- Center for Health Statistics Fact Sheet, Nov. 2015. since-1993/95134818/. H. Gabriel and M. Swain, “E-Prescribing Trends in 6 M. 11 . Squires, “The Shortening American Lifespan,”To D the United States,” ONC Data Brief, No. 18 (Office of the the Point, The Commonwealth Fund, Jan 4. 2017; and National Coordinator for Health Information Technology, A. Case, “‘Deaths of Despair’ Are Killing America’s commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 19 White Working Class,” Quartz, Dec. 30, 2015; https:// S. Hussey, and E. C. Schneider, “Primary Care: A Critical qz.com/583595/deaths-of-despair-are-killing-americas- Review of the Evidence on Quality and Costs of Health white-working-class/. Care,” Health Affairs, May 2010 29(5):766–72. 12 . T. Stewart, D. M. Cutler, and A. B. Rosen, “Forecasting S 18 . McCarthy, D. C. Radley, and S. L. Hayes, Aiming D the Effects of Obesity and Smoking on U.S. Life Higher: Results from a Scorecard on State Health System Expectancy,” New England Journal of Medicine, Performance, 2015 Edition (The Commonwealth Fund, Dec. 3, 2009 361(23):2252–60. Dec. 2015). 13 . Davis, M. K. Abrams, and K. Stremikis, “How the K Affordable Care Act Will Strengthen the Nation’s Primary Care Foundation,” Journal of General Internal Medicine, published online April 27, 2011. 14 he Commonwealth Fund, “Consumers Buy Lower-Cost T Plans on Covered California, Suggesting Exposure to Premium Increases Is Less Than Commonly Reported,” In the Literature, Jan. 9, 2017. See also J. R. Gabel, D. R. Arnold, B. D. Fulton et al., “Consumers Buy Lower-Cost Plans on Covered California, Suggesting Exposure to Premium Increases Is Less Than Commonly Reported,” Health Affairs, Jan. 2017 36(1):8–15. 15 Ibid. 16 n addition to the six indicators mentioned in the I text, California improved on the following indicators: children ages 19–35 months who received all recommended doses of seven key vaccines; Medicare beneficiaries who received at least one drug that should be avoided in the elderly; Medicare beneficiaries with dementia, hip/pelvic fracture, or chronic renal failure who received a prescription drug that is contraindicated for that condition; hospitalized patients given information about what to do during their recovery at home; home health patients who get better at walking or moving around; long-stay nursing home residents with an antipsychotic medication; short-stay nursing home residents with a 30-day readmission to the hospital; and adults with poor health-related quality of life. 17 . Starfield, L. Shi, and J. Macinko, “Contribution of B Primary Care to Health Systems and Health,” Milbank Quarterly, 2005 83(3):457–502; and M. W. Friedberg, P. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 20 ABOUT THE AUTHORS publications. Ms. Hayes holds an M.P.A. from New York David C. Radley, Ph.D., M.P.H., is senior scientist for University’s Wagner School of Public Service, where she The Commonwealth Fund’s Tracking Health System won the Martin Dworkis Memorial Award for academic Performance initiative, working on the Scorecard achievement and public service. She graduated from project. Dr. Radley and his team develop national, state, Dartmouth College with an A.B. in English and began a and substate regional analyses on health care system distinguished career in journalism, working as an editorial performance and related insurance and care system assistant at PC Magazine and a senior editor at National market structure analyses. David is also a senior study Geographic Kids and later at Woman’s Day magazine. director at Westat, a research firm that supports the Following that period, Ms. Hayes was a freelance health Scorecard project. Previously, he was associate in domestic writer and a contributing editor to Parent & Child magazine health policy for Abt Associates, with responsibility for a and cowrote a book on raising bilingual children with a number of projects related to measuring long-term care pediatrician at Tufts Medical Center. quality and evaluating health information technology initiatives. Dr. Radley received his Ph.D. in health ACKNOWLEDGMENTS policy from the Dartmouth Institute for Health Policy We owe our sincere appreciation to all of the researchers and Clinical Practice, and holds a B.A. from Syracuse who developed indicators and conducted data analyses University and an M.P.H. from Yale University. for this Scorecard. These include: Barbara Barton, M.P.H, Douglas McCarthy, M.B.A., is senior research director Agency for Healthcare Research and Quality; Michael E. for The Commonwealth Fund, where he oversees Chernew, Ph.D., and Andrew Hicks, M.S., Department the Fund’s Scorecard project, conducts case-study of Health Care Policy at Harvard Medical School; Sherry research on delivery system reforms and breakthrough Glied, Ph.D., and Ougni Chakraborty, New York University opportunities, and serves as a contributing editor to the Robert F. Wagner Graduate School of Public Service; Ashish Fund’s bimonthly newsletter, Transforming Care. His Jha, M.D., M.P.H., and Jie Zheng, Ph.D., Harvard School 30-year career has spanned research, policy, operations, of Public Health; Vincent Mor, Ph.D., Julie Lima, Ph.D., and consulting roles for government, corporate, Zhanlian Feng, Ph.D., Brown University; and Yuting Zhang, academic, nonprofit, and philanthropic organizations. Ph.D., University of Pittsburgh. He has authored and coauthored reports and peer- We would also like to thank the following Commonwealth reviewed articles on a range of health care–related topics, Fund staff: David Blumenthal, Donald Moulds, Sara including more than 50 case studies of high-performing Collins, Eric Schneider, and Rachel Nuzum for providing organizations and initiatives. Mr. McCarthy received his constructive guidance throughout; and the Fund’s bachelor’s degree with honors from Yale College and a communications team, including Barry Scholl, Chris master’s degree in health care management from the Hollander, Deborah Lorber, Mary Mahon, Christine University of Connecticut. During 1996–1997, he was a Haran, Josh Tallman, Jen Wilson, and Paul Frame, for their public policy fellow at the Hubert H. Humphrey School of guidance, editorial and production support, and public Public Affairs at the University of Minnesota. dissemination efforts. Susan L. Hayes, M.P.A., is senior research associate for Finally, the authors wish to acknowledge Westat for its The Commonwealth Fund’s Tracking Health System support of the research unit, which enabled the analysis Performance initiative. In this role she supports the and development of the Scorecard report, as well as Scorecard project, actively participating in the selection/ Rebecca Birch for her analytic support of the project. development, research, and analysis of national, state, local, and special-population-level health system performance measures, and coauthoring Scorecard reports and related Editorial support was provided by Deborah Lorber. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 21 For more information about this report, please contact: David C. Radley, Ph.D., M.P.H., Senior Scientist, Westat and The Commonwealth Fund Health System Scorecard Project, at dr@cmwf.org. About The Commonwealth Fund The Commonwealth Fund, 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 performance health care system. 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. 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. 1933 commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 22 APPENDIX A1. State Scorecard Data Yearsand Databases Appendix Exhibit A1. State Scorecard Data Years and Databases Indicator Past year Current year Database Access and Affordability 1 Adults ages 19–64 uninsured 2013 2015 ACS PUMS 2 Children ages 0–18 uninsured 2013 2015 ACS PUMS 3 Adults who went without care because of cost in past year 2013 2015 BRFSS 4 Individuals under age 65 with high out-of-pocket medical costs relative to their annual household income —a 2014-15 CPS ASEC 5 At-risk adults without a routine doctor visit in past two years 2013 2015 BRFSS 6 Adults without a dental visit in past year 2012 2014 BRFSS Prevention and Treatment 7 Adults with a usual source of care 2013 2015 BRFSS 8 Adults with age- and gender-appropriate cancer screenings 2012 2014 BRFSS 9 Adults with age-appropriate vaccines 2013 2015 BRFSS 10 Children with a medical home —a 2011/12 NSCH 11 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 care in 12 —a 2011/12 NSCH the past year 13 Children ages 19–35 months who received all recommended doses of seven key vaccines 2013 2015 NIS 14 Medicare beneficiaries who received at least one drug that should be avoided in the elderly 2012 2014 5% Medicare enrolled in Part D Medicare beneficiaries with dementia, hip/pelvic fracture, or chronic renal failure who received a prescription 15 2012 2014 5% Medicare enrolled in Part D drug that is contraindicated for that condition Medicare fee-for-service patients whose health provider always listens, explains, shows respect, and spends 16 2013 2014 CAHPS (via AHRQ National Healthcare Quality Report) enough time with them Risk-adjusted 30-day mortality among Medicare beneficiaries hospitalized for heart attack, heart failure, 17 07/2010 - 06/2013 07/2012 - 06/2015 CMS Hospital Compare pneumonia, or stroke 18 Central line-associated bloodstream infections (CLABSI), Standardized Infection Ratio 2013 2014 CDC HAI Progress Report 19 Hospitalized patients given information about what to do during their recovery at home 2013 2015 HCAHPS (via CMS Hospital Compare) Hospitalized patients who reported hospital staff always managed pain well, responded when needed help to 20 2013 2015 HCAHPS (via CMS Hospital Compare) get to bathroom or pressed call button, and explained medicines and side effects 21 Home health patients who get better at walking or moving around 2013 2015 OASIS (via CMS Home Health Compare) 22 Home health patients whose wounds improved or healed after an operation 2013 2015 OASIS (via CMS Home Health Compare) 23 High-risk nursing home residents with pressure sores 2013 (Q2-Q4) 2015 (Q2-Q4) MDS (via CMS Nursing Home Compare) 24 Long-stay nursing home residents with an antipsychotic medication 2013 (Q2-Q4) 2015 (Q2-Q4) MDS (via CMS Nursing Home Compare) Avoidable Hospital Use and Cost 25 Hospital admissions for pediatric asthma, per 100,000 children 2011 2013 HCUP (via AHRQ National Healthcare Quality Report) Hospital admissions among Medicare beneficiaries for ambulatory care–sensitive conditions, ages 65–74, 26 2012 2014 CCW (via CMS Geographic Variation Public Use File) and 75 and older per 1,000 beneficiaries 27 Medicare 30-day hospital readmissions, rate per 1,000 beneficiaries 2012 2014 CCW (via CMS Geographic Variation Public Use File) 28 Short-stay nursing home residents readmitted within 30 days of hospital discharge to nursing home 2012 2014 MedPAR, MDS 29 Long-stay nursing home residents hospitalized within a six-month period 2012 2014 MedPAR, MDS 30 Home health patients also enrolled in Medicare with a hospital admission 2013 2015 OASIS (via CMS Home Health Compare) 31 Potentially avoidable emergency department visits among Medicare beneficiaries, per 1,000 beneficiaries 2012 2014 Medicare SAF 32 Total reimbursements per enrollee (ages 18–64) with employer-sponsored insurance 2013 2014 Truven MarketScan 33 Total Medicare (Parts A & B) reimbursements per enrollee 2012 2014 CCW (via CMS Geographic Variation Public Use File) Healthy Lives 34 Mortality amenable to health care, deaths per 100,000 population 2011-12 2013-14 CDC NVSS: Mortality Restricted Use File 35 Years of potential life lost before age 75 2012 2014 CDC NVSS: WISQARS 36 Breast cancer deaths per 100,000 female population 2012 2014 CDC NVSS: WONDER 37 Colorectal cancer deaths per 100,000 population 2012 2014 CDC NVSS: WONDER 38 Suicide deaths per 100,000 population 2012 2014 CDC NVSS: WONDER 39 Infant mortality, deaths per 1,000 live births 2012 2013 CDC NVSS: WONDER Adults ages 18–64 who report fair/poor health or activity limitations because of physical, mental, or 40 2013 2015 BRFSS emotional problems 41 Adults who smoke 2013 2015 BRFSS 42 Adults ages 18–64 who are obese (BMI >= 30) 2013 2015 BRFSS 43 Children ages 10–17 who are overweight or obese (BMI >= 85th percentile) —a 2011/12 NSCH 44 Adults ages 18–64 who have lost six or more teeth because of tooth decay, infection, or gum disease 2012 2014 BRFSS Note: (a) Previous data not available or its definition is not comparable over time. Note: (a) Previous data not available or its definition is not comparable over time. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 23 APPENDIX A2. ListList44 44 Indicatorsin the State Scorecard on Health System Performance Appendix Exhibit A2. of of Indicators in the State Scorecard on Health System Performance Range of state Data years represented U.S. average rate 2017 Scorecard performance 2017 2017 2017 Indicator Baseline Scorecard Baseline Scorecard Baseline Scorecard Best state(s) a Access and Affordability 1 Adults ages 19–64 uninsured 2013 2015 20 13 * 5 - 30 4 - 23 MA 2 Children ages 0–18 uninsured 2013 2015 8 5* 2 - 14 1 - 10 MA 3 Adults who went without care because of cost in the past year 2013 2015 16 13 * 7 - 22 7 - 19 IA 4 Individuals with high out-of-pocket medical spending —b 2014-15 —b 14 —b 10 - 19 DC, DE, MD, MN, VT 5 At-risk adults without a doctor visit 2013 2015 14 13 7 - 23 6 - 24 DC, RI 6 Adults without a dental visit in past year 2012 2014 15 16 10 - 20 11 - 20 SD, VT Prevention and Treatment 7 Adults with a usual source of care 2013 2015 76 78 65 - 88 65 - 89 MA 8 Adults with age- and gender-appropriate cancer screenings 2012 2014 69 68 60 - 79 60 - 77 MA 9 Adults with age-appropriate vaccines 2013 2015 36 38 28 - 47 29 - 51 SD 10 Children with a medical home —b 2011/12 —b 54 —b 45 - 69 VT 11 Children with a medical and dental preventive care visit in the past year —b 2011/12 —b 68 —b 56 - 81 VT 12 Children who received needed mental health care in the past year —b 2011/12 —b 61 —b 40 - 86 ND 13 Children ages 19–35 months with all recommended vaccines 2013 2015 70 72 57 - 82 64 - 81 CT 14 Elderly patients who received a high-risk prescription drug 2012 2014 17 13 * 9 - 24 7 - 21 MN 15 Elderly patients who received a contraindicated prescription drug 2012 2014 21 18 * 13 - 28 10 - 23 VT 16 Medicare patients experienced good communication with provider 2013 2014 76 76 72 - 80 71 - 80 MN, VT 07/2010 - 07/2012 - 17 Hospital 30-day mortality 13.2 14.5 * 12.2 - 14.1 13.1 - 15.7 DE 06/2013 06/2015 18 Central line-associated bloodstream infections (CLABSI), Standardized Infection Ratio 2013 2014 0.54 0.5 0.19 - 0.77 0.23 - 0.87 HI 19 Hospital discharge instructions for home recovery 2013 2015 86 87 * 78 - 90 81 - 90 ID, NH, UT, VT, WI 20 Patient-centered hospital care 2013 2015 68 68 58 - 72 58 - 74 ID, SD 21 Home health patients who get better at walking or moving around 2013 2015 61 66 * 49 - 66 54 - 72 AL 22 Home health patients whose wounds healed after an operation 2013 2015 89 90 80 - 93 77 - 95 RI 2013 2015 23 High-risk nursing home residents with pressure sores 6 6 3-9 3-9 AK, ID, NH (Q2-Q4) (Q2-Q4) 2013 2015 24 Nursing home residents with an antipsychotic medication 21 17 * 11 - 27 8 - 22 HI (Q2-Q4) (Q2-Q4) Avoidable Hospital Use and Cost 25 Hospital admissions for pediatric asthma, per 100,000 children 2011 2013 107 107 33 - 232 27 - 226 VT Medicare admissions for ambulatory care–sensitive conditions, ages 65–74 2012 2014 29 27 13 - 51 12 - 46 HI 26 Medicare admissions for ambulatory care–sensitive conditions, age 75 and older 2012 2014 70 66 41 - 100 35 - 92 HI 27 Medicare 30-day hospital readmissions, per 1,000 beneficiaries 2012 2014 34 27 * 12 - 55 10 - 43 HI 28 Short-stay nursing home residents with a 30-day readmission to the hospital 2012 2014 20 19 13 - 26 11 - 25 AK 29 Long-stay nursing home residents with a hospital admission 2012 2014 17 16 7 - 30 5 - 28 HI 30 Home health patients with a hospital admission 2013 2015 16 16.2 14 - 18 13.9 - 17.9 HI 31 Potentially avoidable ED visits among Medicare beneficiaries, per 1,000 beneficiaries 2012 2014 188 185 131 - 248 129 - 265 HI 32 Total reimbursements per enrollee (ages 18–64) with employer-sponsored insurance 2013 2014 $4,489 $4,569 3030 - 7733 3217 - 7982 AR 33 Total Medicare (Parts A & B) reimbursements per enrollee 2012 2014 $8,854 $8,819 5399 - 10868 5592 - 10616 HI Healthy Lives 34 Mortality amenable to health care (deaths per 100,000 population) 2011-12 2013-14 83.9 84.2 55.3 - 132.6 54.3 - 140.8 MN 4891.6 - 35 Years of potential life lost before age 75 2012 2014 6,412 6,447 4891.6 - 9917 MN 9609.6 36 Breast cancer deaths per 100,000 female population 2012 2014 21.4 20.6 15.7 - 31.1 14.2 - 28.9 ND 37 Colorectal cancer deaths per 100,000 population 2012 2014 14.9 14.3 10.7 - 19.4 10.9 - 19.3 WY 38 Suicide deaths per 100,000 population 2012 2014 12.6 13.0 5.7 - 29.6 7.8 - 23.9 DC 39 Infant mortality, deaths per 1,000 live births 2012 2013 6.0 6.0 4.2 - 8.9 4.2 - 9.6 MA 40 Adults with poor health-related quality of life 2013 2015 26 26 20 - 34 20 - 34 MN, ND 41 Adults who smoke 2013 2015 18 17 10 - 27 9 - 26 UT 42 Adults who are obese 2013 2015 29 29 22 - 37 20 - 37 CO 43 Children who are overweight or obese —b 2011/12 —b 31 —b 22 - 40 UT 44 Adults who have lost six or more teeth 2012 2014 10 10 6 - 23 6 - 22 UT Notes: (a) Multiple states may be listed in the event of ties. (b) Previous data not available or its definition is not comparable over time. * Indicates change between baseline and current time periods of at least 0.5 standard deviations (see Scorecard Methodology). Notes: (a) Multiple states may be listed in the event of ties. (b) Previous data not available or its definition is not comparable over time. * Indicates change between baseline and current time periods of at least 0.5 standard deviations (see Scorecard Methods). commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 24 APPENDIX A3. Exhibit StateChange in State HealthIndicator Performance by Indicator Appendix Change in A3. Health System Performance by System Indicator Number of states that: (arranged by number of states with improvement within dimension) • Improveda • No Changeb • Worseneda Access and Affordability 0 Adults ages 19–64 uninsured 49 2 Adults who went without care because of cost in the past year 39 12 Children ages 0–18 uninsured 28 23 At-risk adults without a doctor visit 17 31 3 Adults without a dental visit in past year 42 9 Prevention and Treatment Home health patients who get better at walking or moving around 51 Elderly patients who received a high-risk prescription drug 46 5 Nursing home residents with an antipsychotic medication 46 4 1 Elderly patients who received a contraindicated prescription drug 44 7 Hospital discharge instructions for home recovery 40 10 1 Children ages 19–35 months with all recommended vaccines 24 18 9 Central line-associated bloodstream infections (CLABSI), Standardized Infection Ratio 21 21 9 Adults with age-appropriate vaccines 20 29 2 High-risk nursing home residents with pressure sores 19 27 5 Adults with a usual source of care 17 34 Medicare patients experienced good communication with provider 16 14 21 Home health patients whose wounds healed after an operation 10 38 3 Patient-centered hospital care 6 43 2 Adults with age- and gender-appropriate cancer screenings 6 33 12 Hospital 30-day mortality 1 50 Avoidable Hospital Use and Cost Medicare 30-day hospital readmissions, per 1,000 beneficiaries 34 17 Short-stay nursing home residents with a 30-day readmission to the hospital 20 31 Hospital admissions for pediatric asthma, per 100,000 children 11 40 Medicare admissions for ambulatory care–sensitive conditions, age 75 and older 9 42 Potentially avoidable ED visits among Medicare beneficiaries, per 1,000 beneficiaries 6 43 2 Long-stay nursing home residents with a hospital admission 5 45 1 Medicare admissions for ambulatory care–sensitive conditions, ages 65–74 4 47 Home health patients with a hospital admission 4 30 17 Total reimbursements per enrollee (ages 18–64) with employer-sponsored insurance 2 48 1 Total Medicare (Parts A & B) reimbursements per enrollee 50 1 Healthy Lives Adults who smoke 23 28 Breast cancer deaths per 100,000 female population 18 28 5 Colorectal cancer deaths per 100,000 population 14 32 5 Infant mortality, deaths per 1,000 live births 10 33 8 Adults who have lost six or more teeth 6 44 1 Adults who are obese 3 39 9 Adults with poor health-related quality of life 3 38 10 Suicide deaths per 100,000 population 1 45 5 Mortality amenable to health care 51 Years of potential life lost before age 75 50 1 Notes: Only Scorecard indicators with trends are shown. Trend data generally reflect the two-year period ending in 2014 or 2015—refer to Appendix Exhibit A1 for additional detail (trend data were not available for all indicators). ACS = ambulatory care–sensitive. ACS conditions among Medicare beneficiaries are displayed Notes: separately forindicators with trends are shown. Trend data generally reflect the two-year period ending in 2014 or 2015—refer to Appendix A1 for additional detail (trend data were not here Only Scorecard two age ranges, but counted as a single indicator in tallies of improvement. available for all 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 (a) Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. tallies of improvement. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. (a) Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 25 APPENDIX A4. National Cumulative Impact If All States Acheived TopAchieved Top State Rate Appendix Exhibit A4. National Cumulative Impact if All States State Rate Indicator If all states improved their performance to the level of the best-performing state for this indicator, then: more adults (ages 19–64) would be covered by health insurance (public or private), and therefore would Insured adults 17,382,605 be more likely to receive health care when needed. more children (ages 0–18) would be covered by health insurance (public or private), and therefore Insured children 3,127,276 would be more likely to receive health care when needed. Went without care because of cost 14,688,392 fewer adults (age 18 and older) would go without needed health care because of cost. High out-of-pocket medical spending 10,852,878 fewer individuals would be burdened by high out-of-pocket spending on medical care. more adults (age 18 and older) would have a usual source of care to help ensure that care is Adult usual source of care 26,928,719 coordinated and accessible when needed. more adults would receive age- and gender-appropriate recommended cancer screenings, including Adult cancer screening 12,936,498 tests for colon, breast, and cervical cancers. Adult vaccines 31,824,850 more adults would receive age- appropriate recommended vaccines. more children (ages 0–17) would have a medical home to help ensure that care is coordinated and Children with a medical home 11,109,293 accessible when needed. Children vaccines 513,139 more children (ages 19–35 months) would receive all recommended vaccines. Children with preventive medical and 9,628,054 more children (ages 0–17) would receive annual preventive medical and dental care visits each year. dental visits Medicare received a high-risk drug 1,066,097 fewer Medicare beneficiaries would receive an inappropriately prescribed medication. Preventable hospital admissions among 59,250 fewer children (ages 2–17) would be hospitalized for asthma exacerbations. children Hospital readmissions 124,833 fewer hospital readmissions would occur among Medicare beneficiaries (age 65 and older). Potentially avoidable emergency fewer emergency department visits for nonemergent or primary care–treatable conditions would occur 1,476,533 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 90,032 preventable with timely and appropriate health care. Breast cancer deaths 10,410 fewer women would die from breast cancer. Colon cancer deaths 10,842 fewer individuals would die from colon cancer. Suicides 16,581 fewer individuals would take their own lives. Infant mortality 7,078 more infants would live to see their first birthday. Adults who smoke 19,584,523 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 long-term Adults who are obese 17,753,399 complications. fewer children (ages 10–17) would be overweight or obese, thus reducing the potential for poor health Children who are overweight or obese 3,030,294 as they transition into adulthood. Adults with tooth loss 7,890,400 fewer adults (ages 18–64) would have lost six or more teeth to decay, infection, or gum disease. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 26 APPENDIXExhibit B1. Summary of State Rankings in Current and Previous Scorecards Appendix B1. Summary of State Rankings in Current and Previous Scorecards 2017 Scorecard rankings Access and Prevention and Avoidable Use Healthy Overall ranking Overall Affordability Treatment and Cost Lives Equity in the baseline 2015 Scorecard State ranking dimension dimension dimension dimension dimension time perioda overall rankingb Alabama 47 34 42 41 45 46 39 47 Alaska 36 41 49 12 34 30 34 32 Arizona 32 45 47 7 24 21 36 33 Arkansas 48 45 40 41 48 48 49 49 California 14 24 35 14 5 10 26 23 Colorado 6 23 14 7 5 8 11 8 Connecticut 8 5 5 39 1 8 7 5 Delaware 15 5 10 28 30 21 14 15 District of Columbia 20 5 19 32 33 13 22 20 Florida 39 41 44 45 20 33 39 37 Georgia 41 41 44 23 40 40 45 46 Hawaii Hawaii 3 9 14 1 5 1 3 3 Idaho Idaho 26 45 29 2 14 28 20 25 Illinois Illinois 27 18 23 41 24 25 29 26 Indiana Indiana 44 33 34 36 42 48 45 43 Iowa Iowa 6 8 5 18 14 10 6 9 Kansas Kansas 28 26 20 30 30 31 27 28 Kentucky Kentucky 39 18 29 50 45 43 47 40 Louisiana Louisiana 49 41 42 48 48 44 48 48 Maine Maine 15 21 7 20 27 18 9 11 Maryland Maryland 12 9 16 28 20 13 14 18 Massachusetts Massachusetts 5 2 2 39 3 4 4 4 Michigan Michigan 29 13 16 41 38 33 30 31 Minnesota Minnesota 2 3 7 10 1 5 1 1 Mississippi Mississippi 51 49 50 51 50 51 51 51 Missouri Missouri 37 31 32 32 41 33 34 36 Montana Montana 29 37 35 5 29 33 30 28 Nebraska Nebraska 15 28 18 14 18 16 9 13 Nevada Nevada 46 48 51 19 36 44 41 43 New Hampshire Hampshire New 8 9 4 27 13 6 5 5 New Jersey New Jersey 22 16 20 45 9 16 22 20 New Mexico New Mexico 29 37 47 7 34 15 30 33 New York New York 12 13 23 32 11 6 20 13 North CarolinaNorth Carolina 35 31 23 22 37 37 36 37 North Dakota North Dakota 20 30 13 14 20 21 16 26 Ohio Ohio 32 16 20 32 38 37 30 33 Oklahoma Oklahoma 49 50 38 45 45 47 50 50 Oregon Oregon 22 28 35 3 16 25 24 15 Pennsylvania Pennsylvania 22 12 10 30 27 28 16 20 Rhode Island Rhode Island 4 3 3 20 11 2 7 5 South CarolinaSouth Carolina 41 36 40 23 43 48 41 40 South Dakota South Dakota 15 26 10 10 30 18 16 15 Tennessee Tennessee 44 37 38 36 43 40 38 43 Texas Texas 41 51 44 36 24 37 41 40 Utah Utah 15 40 29 3 4 18 12 18 Vermont Vermont 1 1 1 12 5 2 1 1 Virginia Virginia 25 21 23 23 20 21 24 23 Washington Washington 10 18 23 5 9 10 16 10 West Virginia West Virginia 38 24 23 48 50 32 41 39 Wisconsin Wisconsin 11 13 7 14 16 27 12 11 Wyoming Wyoming 32 34 32 23 18 40 28 28 Notes: (a) The baseline period generally reflects two years prior to the time of observation for the latest year of data available. (b) The 2015 Scorecard Ranking is not based on the same set of indicators used to calculate the 2017 Scorecard and 2017 Scorecard Baseline rankings. Rather, it represents the time period evaluated in the 2015 Scorecard, generally encompassing the years 2013–2014. Notes: (a) The baseline period generally reflects two years prior to the time of observation for the latest year of data available. (b) The 2015 Scorecard Ranking is not based on the same set of indicators used to calculate the 2017 Scorecard and 2017 Scorecard Baseline rankings. Rather, it represents the time period evaluated in the 2015 Scorecard, generally encompassing the years 2013–2014. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 27 APPENDIX Exhibit B2. Summary of Indicator Rankings by State Appendix B2. Summary of Indicator Rankings by State No. of No. of indicators indicators No. of No. of Overall scored Top 5 Top 2nd 3rd Bottom Bottom 5 with trend indicators indicators Net ranking State (of 44) states quartile quartile quartile quartile states (of 39) improved worsened change 47 Alabama 43 2 4 4 15 20 11 38 12 5 7 36 Alaska 43 6 8 11 6 18 15 36 9 10 -1 32 Arizona 44 2 6 14 12 12 5 39 15 4 11 48 Arkansas 44 2 6 4 10 24 15 39 16 2 14 14 California 44 6 15 12 12 5 2 39 14 3 11 6 Colorado 44 7 19 18 4 3 0 39 14 3 11 8 Connecticut 44 10 24 12 3 5 1 39 11 3 8 15 Delaware 42 5 14 11 15 2 2 37 13 4 9 20 District of Columbia 42 13 17 6 7 12 8 35 17 6 11 39 Florida 44 1 3 9 19 13 9 39 12 4 8 41 Georgia 44 1 4 6 20 14 6 39 12 4 8 3 Hawaii 44 19 29 8 4 3 3 37 6 7 -1 26 Idaho 43 9 16 12 6 9 5 38 12 5 7 27 Illinois 44 2 9 12 17 6 2 39 17 1 16 44 Indiana 44 0 0 11 22 11 1 39 15 4 11 6 Iowa 44 9 15 22 6 1 0 39 14 2 12 28 Kansas 44 1 3 20 16 5 2 39 13 5 8 39 Kentucky 44 1 7 7 13 17 10 39 21 4 17 49 Louisiana 44 2 6 2 11 25 22 39 16 6 10 15 Maine 43 8 17 13 10 3 1 38 8 4 4 12 Maryland 43 5 14 14 12 3 3 38 13 2 11 5 Massachusetts 44 18 26 7 9 2 0 39 10 5 5 29 Michigan 44 2 12 8 13 11 1 39 13 1 12 2 Minnesota 44 18 33 5 3 3 1 39 11 3 8 51 Mississippi 43 3 5 1 6 31 29 38 16 4 12 37 Missouri 44 0 4 7 25 8 1 39 13 5 8 29 Montana 44 4 13 9 13 9 3 39 14 4 10 15 Nebraska 44 6 14 16 9 5 4 39 8 4 4 46 Nevada 44 0 5 8 11 20 12 39 10 5 5 8 New Hampshire 43 8 20 15 6 2 1 38 11 9 2 22 New Jersey 44 7 17 10 7 10 7 39 16 1 15 29 New Mexico 43 2 6 11 15 11 6 38 9 4 5 12 New York 44 4 12 17 9 6 3 39 17 2 15 35 North Carolina 44 1 7 13 17 7 1 39 12 1 11 20 North Dakota 44 11 15 12 10 7 2 38 15 4 11 32 Ohio 44 0 4 20 10 10 2 39 11 1 10 49 Oklahoma 44 1 3 6 10 25 13 39 19 2 17 22 Oregon 44 7 16 13 8 7 6 39 11 6 5 22 Pennsylvania 44 2 13 18 11 2 1 39 15 2 13 4 Rhode Island 42 12 24 9 7 2 0 38 14 5 9 41 South Carolina 43 0 3 10 17 13 7 38 11 4 7 15 South Dakota 44 10 19 10 10 5 4 39 15 4 11 44 Tennessee 44 0 2 10 16 16 6 39 16 2 14 41 Texas 44 1 6 9 12 17 9 39 12 3 9 15 Utah 44 14 17 11 7 9 4 39 9 3 6 1 Vermont 42 17 27 11 2 2 0 37 12 4 8 25 Virginia 44 0 5 22 14 3 2 39 14 5 9 10 Washington 44 5 19 14 7 4 0 39 15 2 13 38 West Virginia 44 3 9 5 10 20 14 39 13 3 10 11 Wisconsin 44 10 17 18 4 5 1 39 12 3 9 32 Wyoming 43 8 13 12 8 10 9 38 14 4 10 Notes: Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. Ambulatory care–sensitive conditions among Medicare beneficiaries are displayed here separately for two age ranges, but counted as a single indicator in tallies of improvement. Notes: Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. Ambulatory care–sensitive conditions among Medicare beneficiaries are displayed here separately for two age ranges, but counted as a single indicator in tallies of improvement. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 28 Appendix Exhibit C1. Access & Affordability: Dimension and Indicator Ranking APPENDIX C1. Access & Affordability: Dimension and Indicator Ranking t Overall performance st t hou pa n en et co e 8) re ng Un 9–6 ults No r vi wit of ar Top quartile sp oc k in –1 hild st di e tc it s d ic f-p is Second quartile 4) us u ct ult si s1 a s0 c ar al v ca tho ed -o ge ed ge ed do d Third quartile m out a ka (a sur (a sur al ye ent be w i o s t Bottom quartile in in gh d -ri en Un At Hi W Data not available 1 Vermont 1 0 1 1 1 1 2 Massachusetts 1 1 1 1 1 1 3 Minnesota 1 1 1 1 1 1 3 Rhode Island 1 1 1 1 1 1 5 Connecticut 1 1 2 1 1 1 5 Delaware 1 0 2 1 1 1 5 District of Columbia 1 0 1 1 1 3 8 Iowa 1 1 1 1 2 1 9 Hawaii 1 1 1 1 3 1 9 Maryland 2 1 2 1 1 2 9 New Hampshire 2 1 1 1 1 1 12 Pennsylvania 2 1 2 1 1 1 13 Michigan 2 1 3 2 1 1 13 New York 2 1 2 1 1 3 13 Wisconsin 1 1 1 3 2 1 16 New Jersey 2 1 2 1 1 3 16 Ohio 2 1 2 2 2 2 18 Illinois 2 1 2 2 2 3 18 Kentucky 1 1 2 3 1 3 18 Washington 2 1 2 2 4 1 21 Maine 2 3 1 3 1 1 21 Virginia 3 3 2 2 1 1 23 Colorado 2 1 2 2 4 2 24 California 2 1 2 2 3 3 24 West Virginia 1 1 3 4 1 4 26 Kansas 3 3 2 3 3 1 26 South Dakota 3 4 1 3 3 1 28 Nebraska 2 3 2 2 3 3 28 Oregon 2 1 3 3 4 1 30 North Dakota 2 4 1 3 4 3 31 Missouri 3 3 3 2 3 3 31 North Carolina 3 3 4 4 1 1 33 Indiana 3 3 3 3 4 2 34 Alabama 3 1 4 4 2 4 34 Wyoming 3 3 2 3 4 2 36 South Carolina 3 1 4 3 3 4 37 Montana 3 3 2 4 4 3 37 New Mexico 3 3 3 2 4 4 37 Tennessee 3 1 4 4 3 4 40 Utah 3 4 3 4 4 2 41 Alaska 4 4 3 2 4 3 41 Florida 4 3 4 3 2 3 41 Georgia 4 3 4 3 3 3 41 Louisiana 4 1 4 4 2 4 45 Arizona 3 4 4 3 3 4 45 Arkansas 3 3 4 4 3 4 45 Idaho 4 3 3 4 4 2 48 Nevada 4 4 4 2 4 4 49 Mississippi 4 3 4 4 2 4 50 Oklahoma 4 4 4 4 4 3 51 Texas 4 4 4 3 3 4 commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 29 APPENDIX C2. Access & Affordability: Dimension Ranking and Indicator Rates Appendix Exhibit C2. Access & Affordability: Dimension Ranking and Indicator Rates Individuals Adults who went with high out- without care because of-pocket Adults without a Adults ages 19–64 Children ages 0–18 of cost in the past medical At-risk adults dental visit in past uninsured uninsured year spending without a doctor visit year 2013 2015 2013 2015 2013 2015 2014-15 2013 2015 2012 2014 United States 20% 13% ** 8% 5% ** 16% 13% * 14% 14% 13% 15% 16% Alabama 20 16 * 5 3 * 16 17 17 12 12 18 18 Alaska 24 19 * 12 9 ** 14 14 13 23 24 14 16 * Arizona 24 15 ** 13 9 ** 17 15 * 15 19 16 * 17 18 Arkansas 24 14 ** 6 5 21 16 ** 19 18 15 * 19 18 California 24 12 ** 8 4 ** 16 12 ** 13 17 14 * 16 17 Colorado 19 11 ** 9 4 ** 15 12 * 14 18 17 16 15 Connecticut 13 8 * 4 4 12 11 11 10 10 11 12 Delaware 14 8 ** 5 — 12 11 10 9 9 12 14 * District of Columbia 8 5 * — — 11 9 * 10 9 6 * 16 16 Florida 29 20 ** 12 7 ** 21 17 ** 15 14 12 * 18 17 Georgia 26 19 ** 10 7 ** 20 16 ** 15 14 14 16 17 Hawaii 10 6 * 3 2 9 8 12 14 15 15 14 Idaho 23 17 ** 9 6 ** 16 14 * 18 21 20 13 15 * Illinois 18 10 ** 5 3 * 14 11 * 14 14 12 * 15 16 Indiana 19 13 ** 9 7 * 16 14 * 15 17 17 15 15 Iowa 12 7 * 5 4 10 7 * 12 14 12 * 12 13 Kansas 18 13 * 7 5 * 14 11 * 16 14 15 13 13 Kentucky 21 8 ** 6 4 * 19 12 ** 15 15 11 ** 16 16 Louisiana 25 18 ** 6 4 * 20 16 ** 18 10 13 * 20 20 Maine 16 12 * 5 6 10 9 16 12 11 13 13 Maryland 14 9 * 5 4 13 11 * 10 10 8 * 13 15 * Massachusetts 5 4 2 1 9 9 11 7 7 11 12 Michigan 16 9 ** 5 3 * 15 13 * 13 13 11 * 14 14 Minnesota 11 6 * 6 3 ** 10 8 * 10 12 11 11 13 * Mississippi 25 19 ** 8 5 ** 22 19 * 18 15 12 * 19 20 Missouri 18 13 * 7 6 16 14 * 13 16 15 15 16 Montana 23 16 ** 11 7 ** 14 11 * 18 19 18 17 16 Nebraska 15 11 * 6 5 13 12 13 18 16 * 15 16 Nevada 27 17 ** 14 8 ** 17 15 * 14 15 17 * 20 19 New Hampshire 16 10 ** 4 4 12 9 * 12 11 10 10 12 * New Jersey 19 12 ** 6 4 * 15 12 * 12 10 8 * 15 16 New Mexico 28 16 ** 9 5 ** 18 14 ** 14 17 18 18 18 New York 15 10 * 4 3 15 12 * 11 10 11 15 16 North Carolina 23 16 ** 6 5 18 15 * 17 12 11 15 14 North Dakota 14 9 * 8 9 7 8 15 17 17 15 16 Ohio 16 9 ** 5 4 15 11 ** 14 13 12 14 15 Oklahoma 25 20 * 11 8 ** 17 15 * 18 21 17 ** 18 17 Oregon 21 10 ** 7 4 ** 18 13 ** 16 20 18 * 15 14 Pennsylvania 14 9 * 5 4 12 12 12 12 11 13 14 Rhode Island 17 7 ** 6 3 ** 14 10 ** 11 10 6 ** 12 12 South Carolina 23 16 ** 7 4 ** 19 16 * 16 16 15 18 18 South Dakota 17 16 7 8 10 8 * 16 14 14 11 11 Tennessee 20 15 * 6 4 * 18 16 * 18 11 14 * 17 18 Texas 30 23 ** 13 10 ** 19 18 15 15 16 18 20 * Utah 18 14 * 9 8 15 13 * 17 19 19 16 15 Vermont 10 6 * — — 9 8 10 11 11 11 11 Virginia 17 13 * 6 5 15 12 * 14 12 11 12 14 * Washington 20 9 ** 7 3 ** 15 11 ** 14 17 17 14 14 West Virginia 20 8 ** 5 3 * 18 14 ** 17 12 10 * 18 20 * Wisconsin 13 8 * 5 4 12 9 * 15 13 13 12 12 Wyoming 18 14 * 7 7 14 12 * 16 21 21 15 15 Change 49 28 39 20 9 States Improved 49 28 39 17 0 States Worsened 0 0 0 3 9 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 30 APPENDIX D1. Prevention & Treatment: Dimension and Indicator Ranking Appendix Exhibit D1. Prevention & Treatment: Dimension and Indicator Ranking Overall performance er od l Top quartile es al er id go re in ith a a l ta nc d d cc ca ov d es s w Second quartile en ve ve e pr nce va t ca of si m ei ei m in th vi d d ho e ec ug e c ith ie ed y cc on de de Third quartile rc al lit w pe r sr dr r al ou ed nt en en d 5m d es ta ic ie io e x de ls ne m m te ri or ed Bottom quartile ug iar de –3 ca cia ua m m m at s d re ed va m dr fic ic nt en 19 an co co di fi us n y ca e iv a un tie sk ne in ne da Data not available re re m s al ith a m ge th c -ri be ra e m a 0- ic ith en h ith al re c n nt e b m ep w co a re it ed l3 g fe Li gh e w w in w n he ren re ren hi icar co ar co icar ita m In ral re lts ts ts ic sp ild ild ild ild nt ul ul ed ed ed u Ho Ad Ad Ad Ch Ch Ch Ch Ce sc M M M 1 Vermont 1 2 2 1 1 1 1 1 1 1 3 2 2 Massachusetts 1 1 2 1 1 2 1 1 1 1 1 3 3 Rhode Island 1 1 1 2 1 2 1 1 1 3 1 4 4 New Hampshire 1 1 1 1 1 2 2 2 2 1 2 3 5 Connecticut 1 1 1 2 1 2 1 1 2 1 1 2 5 Iowa 2 2 1 1 2 2 1 1 2 2 4 2 7 Maine 1 1 2 1 1 1 3 2 1 1 2 4 7 Minnesota 3 1 1 1 4 1 2 1 1 1 2 2 7 Wisconsin 2 1 4 1 3 2 4 1 1 1 3 1 10 Delaware 1 1 1 3 2 1 1 2 2 1 1 3 10 Pennsylvania 1 2 2 2 1 1 2 1 2 1 1 1 10 South Dakota 2 2 1 1 4 2 1 1 1 1 3 1 13 North Dakota 4 3 2 1 4 1 1 1 1 2 3 1 14 Colorado 4 2 1 3 2 2 2 2 2 3 2 1 14 Hawaii 1 2 3 2 1 3 2 1 1 1 2 1 16 Maryland 1 1 2 2 1 3 1 2 2 2 0 3 16 Michigan 1 1 4 2 3 1 4 2 3 1 1 1 18 Nebraska 2 3 1 1 2 1 2 1 3 1 4 4 19 District of Columbia 2 1 3 4 1 3 1 2 1 2 1 4 20 Kansas 2 3 2 2 2 1 2 2 3 4 3 4 20 New Jersey 2 2 3 4 1 3 1 1 3 2 1 4 20 Ohio 2 3 4 2 2 2 4 2 3 2 1 1 23 Illinois 1 3 4 3 1 4 3 1 2 1 1 2 23 New York 1 2 2 4 1 2 3 1 3 2 1 3 23 North Carolina 3 1 1 3 3 4 1 4 4 1 3 2 23 Virginia 2 1 2 2 2 4 4 3 3 2 2 1 23 Washington 3 2 2 2 2 4 1 2 2 2 4 3 23 West Virginia 2 4 1 1 1 1 4 3 3 4 3 1 29 Idaho 4 4 4 2 4 4 3 3 2 3 3 1 29 Kentucky 1 3 1 3 3 2 2 4 4 3 2 3 29 Utah 4 2 3 1 4 4 4 3 4 2 3 2 32 Missouri 3 4 1 1 3 2 3 3 3 3 2 2 32 Wyoming 4 4 4 2 3 1 2 2 2 4 4 1 34 Indiana 2 4 4 2 3 3 2 3 3 3 2 4 35 California 3 2 4 4 3 2 2 2 3 4 1 3 35 Montana 4 4 3 2 4 3 4 1 1 3 4 3 35 Oregon 2 2 3 2 4 2 4 2 1 3 4 2 38 Oklahoma 4 4 1 3 4 3 2 4 4 4 2 2 38 Tennessee 3 2 2 2 2 3 3 4 4 3 3 2 40 Arkansas 1 4 2 3 4 1 4 4 4 3 4 3 40 South Carolina 3 3 3 3 3 4 4 4 4 2 2 2 42 Alabama 2 3 3 3 2 4 3 4 4 3 3 4 42 Louisiana 3 3 3 3 3 4 3 4 4 1 1 4 44 Florida 3 3 4 4 4 3 4 3 4 3 1 3 44 Georgia 4 2 4 4 3 4 1 4 4 2 2 4 44 Texas 4 4 2 4 3 3 3 4 4 2 1 2 47 Arizona 4 3 4 4 3 3 3 3 2 4 1 3 47 New Mexico 4 4 3 4 2 3 3 3 2 4 3 3 49 Alaska 4 4 4 4 4 2 4 2 1 3 4 4 50 Mississippi 3 4 3 4 4 4 3 4 4 3 3 4 51 Nevada 4 4 4 4 4 4 3 3 2 4 4 4 Notes: * SIR = Standardized Infection Ratio. Notes: * SIR = Standardized Infection Ratio. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 31 APPENDIX D1. Prevention & Treatment: Dimension and Indicator Ranking (continued) dicatorAppendix Exhibit D1. Prevention & Treatment: Dimension and Indicator Ranking Ranking Overall performance esm ads - er rood er od l ll nt Top quartile nea al r hn tie fo er id go id age s ith citr itu a a a a l al ta edt sn wo n nc acS d d n ed ven es itpa nt d nd eat ov d w es s w io iv a en Second quartile ve ve ov f c n od pr eno e pr nce t ca eid g t ceth io iati the neo ss si ved m c ou mr R* l v ei ei is m csi in th e SI dedo hot vi a i ed ccr no ar edt lruc ruc rew ec ug e c re aliv ith rce ith ie I), nd B ed ity y t cc on pe oh es re Third quartile i al lit g e nt e ddi s w pu r w pe r nd sr dr r va mw or ese sb e d e st ed in e e d sat eec eal nt d 5m d es BS mee g s rim ta ien n so d o 5s c ie at mt ry edn tem re alex io e x de sr ov n t an t ne ii ho te ri r or n de –3n ug iar ac iad Bottom quartile re dtd mo mi de –3 ca cia rue gia LA c ve me rem etde er t e icti csi cyom m at sus at s re ed (C soo va g ca an l i etn 19i dr fic dur ic ic unt ic nt du ho f e en 19 s co a r ss fn di fi ri n ca eipa mf hspa y a ca e iv o v n ec ek r ei un aie un tie sk ne in ne ne io rea da Data not available re thh ed cala rirs ens ai c me io h r-a m s en th-d t e ic lth ltch er zied m ge d e h-p bu ct itne th c -ri be ra e rsy oe m tha m a 0- wis l m agt re wi30 al re aki re c n gh e n nt e b m wi p nitp e b m ep caoe eal al hea co a m nd nt aeid l3 g h nd fe w i fe Li gh e e h it i rk L in he ren re ren he ren re ren sc tisal l l a hi icar co ar co litcsar co r co icar w i-cras an cag he d h ho drtea ita ng ce im In lts l In ral diin a lt t ime ime ic i ur up sp sp sp ild ild ild ld ers dnt nt h ed ed ed ed ed u s il l Mg t Mu Ho Ho Ho Ho Ho Ho Ad Ad Ch Ch Ch Ch Ch Ch Ae Ce Hi M M M M w N C 1 11 1 Vermont 1 1 1 32 22 11 21 31 11 11 21 1 3 2 2 12 Massachusetts 1 1 11 11 3 2 11 31 12 11 21 31 1 1 3 2 13 Rhode Island 1 1 31 11 41 22 31 22 11 11 21 3 1 4 2 24 New2Hampshire 2 11 21 31 11 11 32 32 12 22 1 2 3 2 15 Connecticut 2 1 11 11 21 22 41 42 11 11 22 1 1 2 2 15 1 Iowa 2 22 42 21 21 12 22 31 11 22 2 4 2 1 37 2 Maine 1 11 21 42 11 11 31 23 22 31 1 2 4 1 27 1 Minnesota 1 13 21 21 11 14 41 42 11 11 1 2 2 2 47 1 Wisconsin 1 12 31 14 11 13 42 44 11 11 1 3 1 1 10 1 2 Delaware 2 1 1 11 31 23 32 31 41 12 12 1 1 3 1 10 2 Pennsylvania 2 1 1 1 12 12 22 31 11 32 21 22 1 1 1 2 10 1 South Dakota 1 1 12 32 1 1 11 14 32 41 21 21 1 3 1 1 13 1 North Dakota 1 1 24 3 3 12 4 1 24 11 11 11 31 2 3 1 2 14 2 2 Colorado 2 3 4 22 1 1 23 22 22 12 12 22 3 2 1 3 14 2 1 Hawaii 1 1 1 22 13 42 11 43 42 11 11 1 2 1 3 16 1 2 Maryland 2 2 1 01 32 32 41 13 11 32 12 2 0 3 1 16 4 2 Michigan 3 1 1 11 14 22 13 31 44 32 13 1 1 1 1 18 2 1 Nebraska 3 12 43 4 1 11 12 21 42 11 43 1 4 4 3 19 1 District of Columbia 1 2 22 1 1 43 44 41 13 11 42 11 2 1 4 1 20 2 2 Kansas 3 4 2 33 42 22 12 21 22 22 33 4 3 4 3 20 1 1New Jersey 3 2 2 12 43 44 41 13 11 31 13 2 1 4 2 20 4 2 Ohio 3 2 2 13 14 12 22 22 34 32 43 2 1 1 4 23 3 1 Illinois 2 11 1 3 24 23 31 24 33 31 4 2 1 1 2 2 23 3 1 New York 3 21 1 2 32 44 41 32 2 3 31 23 2 1 3 4 23 1 North Carolina 4 4 1 3 31 21 23 23 34 21 34 14 1 3 2 4 23 4 3 Virginia 3 2 2 21 12 22 32 34 24 3 3 23 2 2 1 4 23 1 Washington 2 2 2 3 4 2 32 22 32 44 31 22 22 2 4 3 1 23 4 West Virginia 3 3 4 2 34 11 21 31 11 24 3 3 23 4 3 1 4 29 3 3 Idaho 2 34 34 14 1 2 14 14 13 13 22 3 3 1 2 29 2 4 Kentucky 4 31 23 31 23 23 1 2 12 34 44 3 2 3 4 29 4 3 Utah 4 24 3 2 23 11 24 14 14 23 34 2 3 2 2 32 3 3 Missouri 3 3 3 24 21 21 33 1 2 13 33 33 3 2 2 1 32 2 2 Wyoming 2 44 44 14 1 2 1 3 41 32 12 12 4 4 1 3 34 2 3 Indiana 3 32 2 4 44 22 2 3 33 22 33 23 3 2 4 2 35 2 2 California 3 4 3 12 34 44 43 32 12 32 13 4 1 3 3 35 4 1 Montana 1 34 44 3 3 22 14 43 14 31 21 3 4 3 2 35 4 2 Oregon 1 32 42 2 3 22 34 42 34 32 21 3 4 2 3 38 2 4 Oklahoma 4 44 24 21 2 3 14 33 12 34 44 4 2 2 3 38 3 4Tennessee 4 3 3 32 22 32 32 13 33 24 44 3 3 2 1 40 4 4 Arkansas 4 31 4 4 32 43 24 11 14 24 24 3 4 3 4 40 4 South Carolina 4 4 23 23 23 23 23 1 4 24 34 14 2 2 2 4 42 3 4 Alabama 4 3 2 33 43 33 22 1 4 13 34 44 3 3 4 4 42 3 4 Louisiana 4 13 13 43 33 13 3 4 13 34 44 1 1 4 3 44 4 3 Florida 4 33 13 3 4 44 44 13 14 33 34 3 1 3 4 44 1 4 Georgia 4 2 4 2 2 44 34 33 14 11 34 44 2 2 4 3 44 3 4 Texas 4 2 4 14 22 34 13 43 43 34 44 2 1 2 3 47 3 3 Arizona 2 4 4 13 34 24 43 43 43 23 22 4 1 3 3 47 3 New Mexico 2 3 4 4 34 33 44 32 43 13 33 22 4 3 3 2 49 4 2 Alaska 1 3 4 44 44 14 34 42 44 12 21 3 4 4 4 50 3 4 Mississippi 4 33 34 43 44 14 14 13 44 44 3 3 4 4 51 3 3 Nevada 2 44 44 44 44 44 44 13 33 22 4 4 4 Notes: * SIR = Standardized Infection Ratio. Notes: (*) SIR is Standardized Infection Ratio commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 32 APPENDIXExhibit D2. Prevention & Treatment: Dimension Ranking and Indicator Rates Appendix D2. Prevention & Treatment: Dimension Ranking and Indicator Rates Children who Children with received a medical and needed Children dental mental Children ages 19–35 Adults with age- and with a preventive health care months with all Medicare benefic Adults with a usual gender-appropriate Adults with age- medical care visit in in the past recommended received a high source of care cancer screenings appropriate vaccines home the past year year vaccines drug 2013 2015 2012 2014 2013 2015 2011/12 2011/12 2011/12 2013 2015 2012 20 United States 76% 78% 69% 68% 36% 38% 54% 68% 61% 70% 72% 17% 1 Alabama 78 79 68 67 38 38 54 70 54 77 71 ** 24 Alaska 67 65 63 62 33 34 52 59 63 64 66 17 Arizona 68 72 * 63 66 * 31 32 46 65 60 65 72 ** 17 Arkansas 77 83 ** 61 63 * 37 40 * 55 62 67 57 67 ** 17 California 71 77 ** 73 70 * 34 35 45 65 63 69 75 ** 16 Colorado 76 76 69 68 42 43 55 70 65 69 75 ** 16 Connecticut 85 85 75 75 37 43 ** 58 79 65 78 81 * 13 Delaware 86 85 75 72 * 43 43 56 72 67 72 79 ** 16 District of Columbia 76 80 * 75 73 * 36 39 * 50 77 59 77 76 13 Florida 73 78 * 68 67 28 29 50 60 58 70 67 * 16 Georgia 72 72 72 70 * 32 34 52 65 53 70 76 ** 21 Hawaii 85 85 70 70 43 38 ** 57 73 58 67 74 ** 21 Idaho 72 73 61 60 32 33 57 59 56 70 72 16 Illinois 80 83 * 67 66 34 35 56 74 55 67 71 * 13 Indiana 80 81 63 62 33 36 * 58 69 58 69 75 ** 17 Iowa 81 81 71 70 44 47 * 67 70 66 78 78 12 Kansas 78 80 68 66 * 40 41 59 70 72 69 75 ** 15 Kentucky 78 83 * 65 67 * 38 43 ** 56 68 66 73 73 23 Louisiana 74 77 * 67 67 39 37 56 67 40 69 71 24 Maine 87 88 73 73 41 41 63 73 78 68 72 * 12 Maryland 79 85 ** 75 73 * 42 41 57 73 59 76 77 15 Massachusetts 88 89 79 77 * 47 42 ** 63 79 65 79 79 9 Michigan 83 85 71 71 33 34 59 68 68 70 68 14 Minnesota 73 77 * 73 72 44 45 61 60 72 74 73 10 Mississippi 77 78 63 64 35 38 * 49 60 53 75 71 * 22 Missouri 79 78 66 64 * 40 43 * 62 65 63 68 71 * 16 Montana 70 74 * 60 63 * 37 39 58 61 60 65 68 * 13 Nebraska 79 80 66 67 43 45 61 70 71 79 74 ** 13 Nevada 65 67 63 63 29 31 45 56 49 61 71 ** 17 New Hampshire 88 88 75 72 * 39 44 ** 67 79 66 75 74 13 New Jersey 81 82 69 69 34 37 * 53 76 58 73 77 * 15 New Mexico 69 71 63 63 36 38 48 70 58 66 70 * 18 New York 81 83 72 70 * 35 40 ** 53 73 64 72 72 12 North Carolina 73 78 * 71 72 44 45 55 67 54 72 76 * 20 North Dakota 73 73 64 66 * 39 42 * 62 61 86 72 80 ** 11 Ohio 81 82 67 66 38 36 57 71 66 62 68 ** 17 Oklahoma 74 75 61 60 41 44 * 56 62 61 63 75 ** 22 Oregon 74 79 * 67 68 33 38 ** 57 63 66 67 67 16 Pennsylvania 86 87 69 68 37 41 * 59 73 69 76 73 * 13 Rhode Island 84 88 * 76 75 42 46 * 60 76 66 82 77 ** 11 South Carolina 76 78 68 67 37 37 54 64 50 67 68 20 South Dakota 76 79 * 68 69 47 51 * 62 59 64 74 76 10 Tennessee 77 78 67 68 42 40 60 70 60 69 70 21 Texas 67 67 66 64 * 34 41 ** 52 68 59 73 71 19 Utah 72 74 68 68 35 38 * 64 61 49 75 68 ** 18 Vermont 87 88 73 70 * 42 42 69 81 78 67 76 ** 11 Virginia 76 79 * 72 71 41 42 57 70 53 69 64 ** 17 Washington 72 77 * 69 69 39 42 * 59 72 54 71 77 ** 16 West Virginia 77 79 66 65 42 44 61 74 74 66 65 17 Wisconsin 81 81 71 73 * 35 36 66 68 65 73 69 * 11 Wyoming 69 69 61 60 32 34 59 65 67 70 73 * 13 Change 17 18 22 33 States Improved 17 6 20 24 States Worsened 0 12 2 9 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 33 APPENDIXExhibit D2. Prevention & Treatment: Dimension Ranking and Indicator Rates Appendix D2. Prevention & Treatment: Dimension Ranking and Indicator Rates (continued) en Children who ed Children with receivedline- Central d a medical and needed associated al Children ages 19–35 Medicare patients Children dental mental bloodstreamChildren ages 19–35 are months with all Medicare beneficiaries Medicare beneficiaries experienced good Adults with age- and with a health care preventive infections (CLABSI), months with all Hospital discharge MedicareHospita benefic ast recommended received a high-risk Adults with a usual gender-appropriate received a Hospital 30-day in in the past communication with medical Adults with age- care visit Standardized recommended for home instructions receivedreceive a high vaccines drug source of care provider contraindicated drug appropriate vaccines cancer screenings year homemortalitypast year Infection Ratio the vaccinesrecovery drug cente 07/2010 - 07/2012 - 12 2013 2015 2012 2013 2014 2015 2012 2012 2014 2014 2013 2013 2015 2014 2011/12 2011/12 06/2013 06/2015 2011/12 2014 2013 2013 2015 2013 2015 2012 2013 20 70% United States 72% 17% 76% 13% ** 78% 69% 21% 68% * 18% 36% 76% 38% 76% 54% 13.2% 14.5% ** 68% 0.54 61% 0.50 70% 86%72% 87% * 17% 68%1 Alabama 77 71 ** 2478 18 ** 79 68 28 6723 ** 3874 3874 54 13.7 15.0 70 ** 0.67 54 0.71 77 85 71 ** 86 * 24 69 Alaska 64 66 1767 12 ** 65 63 17 6212 ** 3376 34 * 75 52 13.7 15.4 59 ** 0.28 63 0.65 ** 64 88 66 89 * 17 70 Arizona 65 72 ** 1768 13 ** 72 * 63 18 6615 * * 3174 32 ** 71 46 13.1 14.2 65 ** 0.64 60 0.53 * 65 86 72 ** 87 * 17 66 Arkansas 57 67 ** 1777 16 ** 83 61 23 6321 * * 3772 40 * ** 74 55 14.1 15.5 62 ** 0.55 67 0.56 57 83 67 ** 84 * 17 68 California 69 75 ** 1671 11 ** 77 ** 73 21 7018 * * 3474 35 * 73 45 13.0 14.0 65 ** 0.52 63 0.51 69 84 75 ** 85 * 16 64 Colorado 69 75 ** 1676 12 ** 76 69 18 6816 * 4276 43 * 75 55 12.9 14.5 70 ** 0.49 65 0.41 * 69 88 75 ** 88 16 70 Connecticut 81 * 78 1385 10 * 85 75 15 7514 3777 43 ** 77 58 13.0 13.9 79 ** 0.56 65 0.45 * 78 85 81 * 87 * 13 65 Delaware 72 79 ** 1686 11 ** 85 75 17 7216 * 4379 43 ** 77 56 12.2 13.1 72 ** 0.71 67 0.55 ** 72 85 79 ** 87 * 16 67 District of Columbia 77 76 1376 12 * 80 75 20 7313 * ** 3679 39 * ** 76 50 12.4 13.6 77 ** 0.70 59 0.60 * 77 78 76 81 ** 13 58 Florida 70 67 * 1673 14 ** 78 68 21 6719 * 2876 29 * 75 50 13.1 14.2 60 ** 0.59 58 0.51 * 70 83 67 * 85 * 16 63 Georgia 70 76 ** 2172 16 ** 72 72 21 7019 * * 3276 3476 52 13.4 14.7 65 ** 0.72 53 0.64 * 70 84 76 ** 86 * 21 66 Hawaii 67 74 ** 2185 85 ** 9 70 18 7013 ** 4377 38 ** 77 57 13.4 14.7 73 ** 0.25 58 0.23 67 85 74 ** 83 * 21 69 Idaho 70 72 1672 13 * 73 61 22 6016 ** 3274 3374 57 13.6 15.0 59 ** 0.29 56 0.35 * 70 88 72 90 * 16 70 Illinois 67 71 * 1380 10 ** 83 67 18 6616 * 3477 35 * 78 56 12.9 14.1 74 ** 0.47 55 0.43 67 86 71 * 87 * 13 67 Indiana 69 75 ** 1780 13 ** 81 63 21 6218 * 3376 36 * * 75 58 13.4 14.6 69 ** 0.69 58 0.61 * 69 87 75 ** 88 * 17 69 Iowa 78 78 1281 81 * 9 71 17 7014 * 4475 47 * * 76 67 13.4 15.1 70 ** 0.54 66 0.46 * 78 88 78 88 12 69 Kansas 69 75 ** 1578 12 * 80 68 20 6617 * * 4075 41 ** 73 59 13.0 14.9 70 ** 0.58 72 0.61 69 86 75 ** 88 * 15 70 Kentucky 73 73 2378 17 ** 83 * 65 24 6720 * ** 3877 43 **** 75 56 13.3 14.7 68 ** 0.67 66 0.55 * 73 86 73 87 * 23 69 Louisiana 69 71 2474 21 ** 77 67 23 6721 * 3980 37 ** 78 56 13.3 14.2 67 ** 0.69 40 0.60 * 69 86 71 86 24 72 Maine 68 72 * 1287 12 88 73 13 7312 4177 41 * 78 63 13.4 14.4 73 ** 0.66 78 0.87 ** 68 89 72 * 89 12 72 Maryland 76 77 1579 12 *** 85 75 18 7316 * * 4276 4176 57 12.8 — 73 0.51 59 0.53 76 85 77 86 * 15 61 Massachusetts79 79 988 89 9 79 15 7713 * * 4777 42 **** 79 63 12.4 13.2 79 ** 0.51 65 0.50 79 87 79 89 * 9 67 Michigan 70 68 1483 12 * 85 71 19 7117 * 3375 34 ** 77 59 13.0 14.2 68 ** 0.44 68 0.40 70 87 68 88 * 14 68 Minnesota 74 73 1073 77 ** 7 73 15 7213 * 4478 45 ** 80 61 12.8 14.3 60 ** 0.44 72 0.45 74 88 73 89 * 10 71 Mississippi 75 71 * 2277 19 * 78 63 26 6423 * 3578 38 * ** 75 49 13.4 14.9 60 ** 0.77 53 0.76 75 83 71 * 85 * 22 70 Missouri 68 71 * 1679 14 * 78 66 21 6418 * * 4077 43 * ** 74 62 13.2 14.5 65 ** 0.42 63 0.48 * 68 87 71 * 88 * 16 67 Montana 65 68 * 1370 10 ** 74 60 17 6313 * ** 3777 39 ** 74 58 13.2 15.2 61 ** 0.63 60 0.56 * 65 85 68 * 87 * 13 67 Nebraska 79 74 ** 1379 10 * 80 66 21 6718 * 4379 45 ** 77 61 13.3 15.3 70 ** 0.71 71 0.72 79 88 74 ** 89 * 13 72 Nevada 61 71 ** 1765 13 ** 67 63 18 6315 * 2973 3173 45 13.8 15.2 56 ** 0.63 49 0.58 61 84 71 ** 84 17 64 New Hampshire 75 74 1388 11 * 88 75 19 7214 * ** 3978 44 *** 77 67 13.3 14.4 79 ** 0.35 66 0.55 ** 75 88 74 90 * 13 69 New Jersey 77 * 73 1581 10 ** 82 69 18 6917 3476 37 * 76 53 12.7 13.7 76 ** 0.61 58 0.59 73 82 77 * 84 * 15 63 New Mexico 70 * 66 1869 13 ** 71 63 21 6316 ** 3673 38 * 72 48 13.3 14.8 70 ** 0.49 58 0.55 * 66 84 70 * 84 18 66 New York 72 72 1281 83 * 9 72 17 7017 * 3575 40 *** 76 53 13.1 14.2 73 ** 0.56 64 0.50 * 72 84 72 85 * 12 63 North Carolina76 * 72 2073 15 ** 78 * 71 21 7219 * 4476 45 * 77 55 13.7 14.9 67 ** 0.53 54 0.42 * 72 87 76 * 87 20 69 North Dakota 80 ** 72 1173 73 * 8 64 14 6611 * * 3973 42 * ** 76 62 12.7 14.9 61 ** 0.37 86 0.39 72 82 80 ** 82 11 70 Ohio 62 68 ** 1781 12 ** 82 67 20 6617 * 3876 3676 57 12.9 14.0 71 ** 0.42 66 0.40 62 87 68 ** 89 * 17 68 Oklahoma 63 75 ** 2274 18 ** 75 61 26 6021 ** 4176 44 * ** 73 56 13.2 14.7 62 ** 0.39 61 0.43 63 85 75 ** 87 * 22 70 Oregon 67 67 1674 11 ** 79 * 67 17 6813 ** 3374 38 ** 74 57 13.9 15.3 63 ** 0.30 66 0.48 ** 67 86 67 88 * 16 68 Pennsylvania 73 * 76 1386 10 * 87 69 18 6815 * 3778 41 * 78 59 12.9 14.1 73 ** 0.49 69 0.41 * 76 86 73 * 87 * 13 67 Rhode Island 77 ** 82 1184 88 ** 9 76 13 7513 4277 46 * ** 75 60 13.2 13.7 76 * 0.67 66 0.61 * 82 86 77 ** 87 * 11 67 South Carolina68 67 2076 17 * 78 68 22 6721 3777 37 * 76 54 13.5 14.6 64 ** 0.58 50 0.49 * 67 86 68 87 * 20 69 South Dakota 76 74 1076 79 ** 8 68 15 6912 * 4777 51 * 77 62 13.1 15.0 59 ** 0.19 64 0.25 * 74 87 76 89 * 10 72 Tennessee 70 69 2177 16 ** 78 67 24 6821 * 4275 4075 60 13.5 15.0 70 ** 0.49 60 0.48 69 85 70 86 * 21 68 Texas 73 71 1967 16 * 67 66 22 6419 * * 3475 41 *** 76 52 13.0 14.2 68 ** 0.51 59 0.47 73 86 71 86 19 69 Utah 75 68 ** 1872 13 ** 74 68 23 6820 * 3575 38 * * 76 64 13.5 14.8 61 ** 0.66 49 0.45 ** 75 90 68 ** 90 18 70 Vermont 67 76 ** 1187 88 * 9 73 14 7010 * ** 4275 42 ** 80 69 13.8 14.9 81 ** 0.25 78 0.45 ** 67 88 76 ** 90 * 11 69 Virginia 69 64 ** 1776 13 ** 79 * 72 20 7117 * 4175 42 * 76 57 13.5 14.5 70 ** 0.50 53 0.39 * 69 86 64 ** 88 * 17 66 Washington 77 ** 71 1672 12 ** 77 * 69 17 6914 * 3974 42 * ** 76 59 13.9 15.2 72 ** 0.54 54 0.51 71 87 77 ** 88 * 16 66 West Virginia 65 66 1777 14 * 79 66 20 6518 * 4273 4473 61 13.2 14.8 74 ** 0.35 74 0.38 66 85 65 87 * 17 67 Wisconsin 73 69 * 1181 81 * 9 71 15 7313 * * 3578 36 * 79 66 13.5 14.9 68 ** 0.48 65 0.35 ** 73 89 69 * 90 * 11 71 Wyoming 70 73 * 1369 12 69 61 22 6014 ** 3274 34 ** 72 59 13.0 15.7 65 ** 0.53 67 0.37 ** 70 88 73 * 89 * 13 69 Change 33 46 17 18 44 2237 50 30 33 41 States Improved 24 46 17 644 2016 0 21 24 40 States Worsened9 00 12 0 221 50 9 9 1 . Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 34 APPENDIXExhibit D2. Prevention & Treatment: Dimension Ranking and Indicator Rates Appendix D2. Prevention & Treatment: Dimension Ranking and Indicator Rates (continued) Children who e- Children with received d a medical and needed m Home health patients Children dental mental home Nursing Children ages 19–35 ABSI), Hospital discharge who get better at Hospitalized adults Adults with age- and preventive health care with an Home health patientswithHigh-risk nursing a residents months with all Medicare benefic ed instructions for home walking or moving Adults with age- healed home residents with in the past Adults with a usual gender-appropriate received patient- whose wounds medical care visit in antipsychoticrecommended received a high tio recovery centered care source of care around after an operation home cancer screenings appropriate vaccines pressure past year the sores year medication vaccines drug 2013 2015 2013 2015 014 2013 2015 2013 2013 2015 2015 2012 2013 20142015 20132013 2015 2015 2011/12 (Q2-Q4) 2011/12 (Q2-Q4) (Q2-Q4) 2011/12 (Q2-Q4) 2013 2015 2012 20 0.50 United States 86% 87% * 76% 68% 78% 68% 69%61% 68% 66% ** 36% 89% 38% 90% 54% 6% 68% 6% 61% 21% 17%70% ** 72% 17% 1 0.71 Alabama 85 86 * 78 69 7969 65 68 67 72 ** 38 91 38 91 54 5 70 6 * 5422 20 77 * 71 ** 24 0.65 ** Alaska88 89 * 67 70 6567 ** 49 63 62 54 ** 33 80 34 77 ** 52 6 59 3 ** 6313 15 64 * 66 17 0.53 * Arizona 86 87 * 68 66 7266 * 58 63 66 * 62 * 31 86 32 86 46 6 65 5 * 6020 17 65 * 72 ** 17 0.56 Arkansas 83 84 * 77 68 8369 ** 61 61 63 * 70 ** 37 90 40 * 91 55 6 62 5 * 6724 17 ** 57 67 ** 17 0.51 California 84 85 * 71 64 7764 ** 59 73 70 * 65 ** 34 91 35 92 45 6 65 6 6317 13 ** 69 75 ** 16 0.41 * Colorado 88 88 76 70 7669 62 69 68 67 ** 42 90 43 91 55 5 70 4 * 6517 16 69 75 ** 16 0.45 * Connecticut 85 87 * 85 65 8565 59 75 75 63 * 37 90 43 ** 91 58 4 79 4 6521 17 ** 78 81 * 13 0.55 ** Delaware 85 87 * 86 67 8567 58 75 72 * 66 ** 43 82 43 84 * 56 6 72 4 ** 6717 13 ** 72 79 ** 16 0.60 * District of Columbia 78 81 ** 76 58 8058 * 60 75 73 * 70 ** 36 90 39 * 94 ** 50 9 77 9 5916 14 77 * 76 13 0.51 * Florida 83 85 * 73 63 7864 * 65 68 67 69 * 28 92 29 92 50 6 60 6 5822 18 ** 70 67 * 16 0.64 * Georgia 84 86 * 72 66 7267 61 72 70 * 68 ** 32 90 34 91 52 7 65 7 5322 20 70 * 76 ** 21 0.23 Hawaii85 83 * 85 69 8570 55 70 70 61 ** 43 83 38 ** 83 57 3 73 4 * 5811 8 67 * 74 ** 21 0.35 * Idaho 88 90 * 72 70 7374 ** 63 61 60 68 ** 32 91 33 91 57 4 59 3 * 5620 16 ** 70 72 16 0.43 Illinois 86 87 * 80 67 8368 * 61 67 66 67 ** 34 88 35 89 56 7 74 6 * 5525 21 ** 67 71 * 13 0.61 * Indiana 87 88 * 80 69 8169 59 63 62 66 ** 33 89 36 * 90 58 7 69 6 * 5821 17 ** 69 75 ** 17 0.46 * Iowa88 88 81 69 8171 * 62 71 70 67 ** 44 88 47 * 88 67 5 70 4 * 6620 17 78 * 78 12 0.61 Kansas86 88 * 78 70 8070 61 68 66 * 67 ** 40 88 41 90 * 59 5 70 5 7222 19 69 * 75 ** 15 0.55 * Kentucky 86 87 * 78 69 8369 * 64 65 67 * 70 ** 38 91 43 ** 91 56 7 68 7 6622 20 73 * 73 23 0.60 * Louisiana 86 86 74 72 7773 * 60 67 67 66 ** 39 92 37 91 56 9 67 7 ** 4027 22 ** 69 71 24 0.87 ** Maine 89 89 87 72 8871 62 73 73 66 * 41 88 41 90 * 63 5 73 5 7821 18 68 * 72 * 12 0.53 Maryland 85 86 * 79 61 8562 ** 63 75 73 * 68 ** 42 89 41 91 * 57 7 73 7 5916 14 76 * 77 15 0.50 Massachusetts 89 87 * 88 67 8967 63 79 77 * 68 ** 47 92 42 ** 93 63 5 79 5 6522 19 79 * 79 9 0.40 Michigan 87 88 * 83 68 8570 * 61 71 71 66 ** 33 87 34 87 59 6 68 6 6815 13 70 * 68 14 0.45 Minnesota 88 89 * 73 71 7771 * 57 73 72 62 ** 44 85 45 85 61 4 60 4 7216 13 74 * 73 10 0.76 Mississippi 83 85 * 77 70 7870 64 63 64 71 ** 35 92 38 * 94 * 49 8 60 8 5325 21 ** 75 71 * 22 0.48 * Missouri 87 88 * 79 67 7867 62 66 64 * 68 ** 40 90 43 * 91 62 6 65 6 6324 19 ** 68 71 * 16 0.56 * Montana 85 87 * 70 67 7470 ** * 56 60 63 * 63 ** 37 92 39 92 58 5 61 6 * 6018 15 65 * 68 * 13 0.72 Nebraska 88 89 * 79 72 8072 59 66 67 67 ** 43 83 45 82 61 4 70 4 7123 20 79 * 74 ** 13 0.58 Nevada84 84 65 64 6762 * 60 63 63 64 * 29 91 31 91 45 7 56 7 4921 17 ** 61 71 ** 17 0.55 ** New88 Hampshire 90 * 88 69 8870 59 75 72 * 65 ** 39 87 44 ** 88 67 4 79 3 * 6621 17 ** 75 74 13 0.59 New82 Jersey 84 * 81 63 8263 63 69 69 69 ** 34 90 37 * 91 53 8 76 7 * 5816 13 73 * 77 * 15 0.55 * New84 Mexico 84 69 66 7167 59 63 63 64 ** 36 93 38 92 48 6 70 6 5819 16 66 * 70 * 18 0.50 * New84 York 85 * 81 63 8363 59 72 70 * 66 ** 35 89 40 ** 90 53 8 73 7 * 6419 16 72 * 72 12 0.42 * North Carolina 87 87 73 69 7869 * 61 71 72 66 ** 44 90 45 90 55 7 67 7 5416 14 72 * 76 * 20 0.39 North Dakota 82 82 73 70 7369 56 64 66 * 69 ** 39 87 42 * 91 ** 62 4 61 4 8619 19 72 80 ** 11 0.40 Ohio87 89 * 81 68 8269 61 67 66 67 ** 38 88 36 88 57 6 71 6 6623 20 62 * 68 ** 17 0.43 Oklahoma 85 87 * 74 70 7570 60 61 60 66 ** 41 91 44 * 92 56 8 62 7 * 6123 20 63 * 75 ** 22 0.48 ** Oregon86 88 * 74 68 7968 * 56 67 68 61 ** 33 89 38 ** 89 57 6 63 7 * 6618 17 67 67 16 0.41 * Pennsylvania 86 87 * 86 67 8767 63 69 68 68 ** 37 87 41 * 89 * 59 6 73 5 * 6919 17 76 * 73 * 13 0.61 * Rhode Island 86 87 * 84 67 8868 * 63 76 75 67 * 42 93 46 * 95 * 60 5 76 4 * 6618 17 82 77 ** 11 0.49 * South Carolina 87 86 * 76 69 7869 64 68 67 68 * 37 92 37 90 * 54 6 64 7 * 5017 14 67 * 68 20 0.25 * South Dakota 87 89 * 76 72 7974 * * 58 68 69 66 ** 47 88 51 * 83 ** 62 5 59 5 6419 17 74 * 76 10 0.48 Tennessee 85 86 * 77 68 7868 63 67 68 68 ** 42 90 40 89 60 5 70 5 6024 20 ** 69 70 21 0.47 Texas 86 86 67 69 6770 56 66 64 * 60 * 34 88 41 ** 87 52 7 68 6 * 5927 21 ** 73 71 19 0.45 ** Utah90 90 72 70 7469 66 68 68 71 ** 35 92 38 * 91 64 5 61 5 4925 18 ** 75 68 ** 18 0.45 ** Vermont 88 90 * 87 69 8869 60 73 70 * 66 ** 42 88 42 91 ** 69 4 81 4 7820 17 67 * 76 ** 11 0.39 * Virginia 86 88 * 76 66 7967 * 63 72 71 66 * 41 90 42 90 57 6 70 6 5320 17 69 * 64 ** 17 0.51 Washington 87 88 * 72 66 7767 * 56 69 69 62 ** 39 88 42 * 88 59 6 72 5 * 5419 16 71 * 77 ** 16 0.38 West Virginia 85 87 * 77 67 7967 63 66 65 70 ** 42 91 44 90 61 7 74 7 7418 16 66 * 65 17 0.35 ** Wisconsin 89 90 * 81 71 8171 59 71 73 * 64 ** 35 87 36 87 66 4 68 4 6516 13 73 * 69 * 11 0.37 ** Wyoming 88 89 * 69 69 6971 * 58 61 60 61 * 32 88 34 88 59 5 65 4 * 6718 13 ** 70 73 * 13 30 Change 41 17 8 18 51 22 13 24 47 33 21 States Improved 40 17 6 6 51 20 10 19 46 24 9 States Worsened 1 0 2 12 0 2 3 5 1 9 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 35 APPENDIX E1 . Avoidable Hospital Use & Cost: Dimension and Indicator Ranking Overall performance Appendix Exhibit E1. Avoidable Hospital Use & Cost: Dimension and Indicator Ranking Top quartile Second quartile 4 d –7 l es ry e ry an ita Third quartile 30 nts a g to a g to 65 s ry ys sp 75 nt re ic s, la s, la ia in de ce da ild tr ho on ide y on bu on bu ic s nc n) ch edia on Bottom quartile e ra n ith si ef iti m iti m a is res ge w re en si ith nd r a nd a ol su 00 r p is er on me or dm e rb sw co fo m nr in l a om Data not available is em si 0, fo sf pe is ho ad ns r e red nt le 0 10 ns ve n ita h t v ble re ng tiv io iti sio m ng tie g er io its pe so co sp in si ss ay di en a si ad si (p iss de ns is on pa ng on m id ho rs e en mi en re nur -d ol se dm rt vo m dm a nu is lth di sp 30 –s d sp re e a re e a pa e a y en r- m ea ith ay th l a ith a e e sp oye w t-st ca ar ca car ar de car ar si as ita ad h w -st a e ic ic a ic – sp pl r ng i i m or ed ed ed ed ed Em Ho Ho Sh Lo M M M M M 1 Hawaii 2 1 1 1 1 1 1 1 1 1 2 Idaho 0 1 1 1 1 1 1 2 1 1 3 Oregon 1 1 1 1 1 1 1 1 3 1 3 Utah 2 1 1 1 1 1 1 1 3 2 5 Montana 1 1 1 1 1 1 1 1 2 1 5 Washington 1 1 1 1 1 1 1 1 3 1 7 Arizona 3 1 1 1 2 1 1 2 2 2 7 Colorado 3 1 1 1 1 1 1 2 3 1 7 New Mexico 0 2 2 1 2 2 1 2 1 1 10 Minnesota 1 1 1 1 1 1 3 2 3 1 10 South Dakota 1 2 2 2 1 2 1 1 4 1 12 Alaska 0 1 1 2 1 1 1 4 4 1 12 Vermont 1 1 0 2 1 2 2 1 4 1 14 California 2 1 1 1 3 3 1 1 3 2 14 Nebraska 1 2 2 2 1 2 3 1 3 2 14 North Dakota 1 2 2 2 1 2 4 2 3 2 14 Wisconsin 2 2 2 1 1 1 2 2 4 2 18 Iowa 1 2 2 2 1 2 3 3 2 2 19 Nevada 3 2 1 2 4 3 1 1 2 2 20 Maine 0 2 2 2 1 1 3 4 2 2 20 Rhode Island 0 3 0 2 3 1 3 4 1 3 22 North Carolina 3 3 2 2 2 2 2 4 2 2 23 Georgia 2 3 3 2 3 3 3 3 1 3 23 South Carolina 3 2 2 2 3 3 3 2 0 2 23 Virginia 2 2 2 3 3 3 3 3 2 2 23 Wyoming 3 0 0 2 1 2 4 1 4 1 27 New Hampshire 0 2 2 3 2 2 4 2 4 2 28 Delaware 0 3 3 4 3 2 2 1 3 3 28 Maryland 3 3 2 4 3 2 2 3 1 3 30 Kansas 4 2 2 3 2 3 4 2 2 3 30 Pennsylvania 4 3 3 2 2 2 3 2 3 4 32 District of Columbia 0 4 3 4 2 3 2 4 1 3 32 Missouri 4 3 3 3 3 3 3 4 2 3 32 New York 4 2 3 2 4 2 3 2 4 3 32 Ohio 3 4 4 2 3 2 2 4 2 4 36 Indiana 2 4 4 3 2 3 3 3 4 3 36 Tennessee 2 4 4 3 2 3 4 3 2 4 36 Texas 3 3 3 2 3 4 1 3 4 4 39 Connecticut 4 2 3 4 2 2 3 3 4 3 39 Massachusetts 4 3 4 4 2 2 3 3 3 3 41 Alabama 0 4 4 4 3 3 4 3 1 4 41 Arkansas 1 4 4 4 4 4 4 3 1 3 41 Illinois 3 3 4 4 3 4 2 3 3 4 41 Michigan 2 4 4 4 4 3 3 4 1 4 45 Florida 4 3 3 3 4 4 2 3 3 4 45 New Jersey 4 3 3 4 4 4 2 1 4 4 45 Oklahoma 4 4 3 3 4 4 2 4 2 4 48 Louisiana 4 4 4 3 4 4 2 4 1 4 48 West Virginia 2 4 4 4 3 3 4 4 4 3 50 Kentucky 3 4 4 4 3 4 4 4 2 4 51 Mississippi 0 4 4 4 4 4 4 4 1 4 commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 36 APPENDIX E2. Avoidable Avoidable Hospital Use & Cost: Dimension Ranking and Indicator Rates Appendix Exhibit E2. Hospital Use & Cost: Dimension Ranking and Indicator Rates Medicare admissions Medicare admissions for ambulatory Short-stay nursing Hospital admissions for for ambulatory care–sensitive Medicare 30-day home residents with a Long-sta pediatric asthma, per care–sensitive conditions, age 75 and hospital readmissions, 30-day readmission to home resid 100,000 children conditions, ages 65–74 older per 1,000 beneficiaries the hospital hospital 2011 2013 2012 2014 2012 2014 2012 2014 2012 2014 2012 United States 107 107 29 27 70 66 34 27 * 20% 19% 17% Alabama — — 38 35 82 75 * 39 33 * 22 20 * 21 Alaska 46 — — 16 52 48 29 23 * — 11 — Arizona 106 91 20 17 51 47 23 19 20 19 9 Arkansas 64 54 35 32 83 77 42 35 * 25 23 * 26 California 87 88 21 18 55 50 24 19 * 22 20 * 20 Colorado 143 117 * 16 15 50 46 19 16 16 14 * 10 Connecticut 144 126 26 24 75 69 39 33 * 20 19 16 Delaware — — 27 29 68 69 40 38 20 20 19 District of Columbia — — 37 35 — 67 55 43 ** — 19 — Florida 145 157 28 29 68 72 34 30 22 22 23 Georgia 88 87 31 29 73 70 33 27 * 21 20 19 Hawaii 52 66 13 12 41 35 12 10 — 12 — Idaho — — 17 15 45 42 17 15 14 14 11 Illinois 117 110 31 28 73 73 51 38 ** 23 20 * 22 Indiana 105 78 * 35 32 77 73 40 32 * 20 18 * 19 Iowa 69 56 24 22 64 59 33 28 * 17 16 15 Kansas 144 128 27 26 71 65 37 32 * 19 18 20 Kentucky 167 117 ** 51 46 * 100 92 * 50 37 ** 22 20 * 24 Louisiana 232 145 ** 44 41 97 90 * 40 32 * 26 25 30 Maine 72 — 26 25 65 60 31 27 17 16 12 Maryland 132 123 29 29 69 65 49 40 ** 22 20 * 17 Massachusetts 182 126 ** 30 28 80 77 41 35 * 19 19 14 Michigan 97 88 34 34 73 74 42 36 * 23 21 * 18 Minnesota 70 57 20 19 55 53 18 14 17 16 7 Mississippi — — 42 40 91 91 48 41 * 24 22 * 29 Missouri 150 127 * 31 30 73 69 37 32 * 22 20 * 20 Montana 65 53 21 18 — 51 25 21 13 13 12 Nebraska 58 43 24 23 63 58 33 28 * 16 15 16 Nevada 98 107 25 22 60 55 26 23 23 22 20 New Hampshire — — 23 22 64 65 34 31 16 17 14 New Jersey 149 151 27 27 73 69 47 40 * 24 22 * 21 New Mexico — — 23 21 59 56 22 19 18 18 13 New York 221 226 29 25 * 73 66 * 36 28 * 23 21 * 17 North Carolina 109 112 29 28 67 64 35 27 * 20 18 * 18 North Dakota — 48 24 22 65 61 35 28 * 16 14 * 15 Ohio 143 125 38 36 82 75 * 34 27 * 21 20 15 Oklahoma 139 136 38 34 * 80 72 * 40 32 * 23 21 * 24 Oregon 40 39 17 17 48 45 15 14 17 16 8 Pennsylvania 187 166 * 31 28 74 69 31 26 * 21 19 * 16 Rhode Island 139 — 27 28 66 — 28 26 21 20 10 South Carolina 138 124 27 26 65 61 33 28 * 20 20 20 South Dakota 72 46 * 22 21 — 60 31 25 * 15 14 15 Tennessee 98 69 * 37 34 84 77 * 37 29 * 21 19 * 22 Texas 104 90 31 30 76 72 34 27 * 22 20 * 23 Utah 80 68 17 15 42 39 17 15 14 14 11 Vermont 33 27 — 20 65 — 31 26 * 16 15 15 Virginia 107 87 * 27 24 71 62 * 40 32 * 21 20 20 Washington 77 62 18 17 49 46 23 20 17 16 13 West Virginia 110 86 * 50 42 ** 98 81 ** 46 35 ** 23 20 * 19 Wisconsin 78 73 22 21 60 57 26 21 * 17 16 12 Wyoming 92 99 — — — — 32 28 15 14 13 Change 11 4 9 34 20 States Improved 11 4 9 34 20 States Worsened 0 0 0 0 0 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. Spending estimates exclude prescription drug costs and are adjusted fo estimates are not available. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. Spending estimates exclude prescription drug costs and are adjusted for regional wage differences; Medicare estimates reflect only the age 65+ fee-for-service Medicare population. — Indicates that estimates are not available. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 37 APPENDIX E2. Avoidable Avoidable Hospital Use & Cost: Dimension Ranking and Indicator Rates Appendix Exhibit E2. Hospital Use & Cost: Dimension Ranking and Indicator Rates (continued) icator Rates Medicare admissions Short-stay nursing Medicare admissions Potentially avoidable Total reimbursements for ambulatory Short-stay nursing y home residents with a Long-stay nursing for Hospital admissions Home health patients for ambulatory ED visits among care–sensitive Medicare 30-day Total Medicare (Parts A a per enrollee (ages home residents with Long-sta ons, 30-day readmission to home residents with a pediatric asthma, per with a hospital care–sensitive Medicare beneficiaries, 18–64) withreadmissions, & 30-day readmission to conditions, age 75 and hospital employer- B) reimbursements home resid ries the hospital hospital admission 100,000 children conditions, ages 65–74 1,000 beneficiaries admission per older sponsored insurance per 1,000 beneficiaries per enrollee the hospital hospital 4 2012 2014 2012 2011 2014 2013 2013 2012 2015 2014 2012 2012 2014 2014 2013 2012 2014 2014 2012 2012 2014 2014 2012 7* 20% States United 19% 17%107 16%107 16 29 16 27 188 70 185 66 $4,489 34$4,569 27 * $8,85420%$8,81919% 17% 3 * Alabama 22 20 * 21 — 19 — 17 38 18 * 35 192 82 187 75 * 3,634 39 3,677 33 * 9,344 22 9,228 20 * 21 3 * Alaska — 11 — 46 11 — 14 — 14 16 205 52 204 48 7,733 29 7,982 23 * 5,399 — 6,110 11 * — 9 Arizona 20 19 9106 8 91 15 20 15 17 178 51 173 47 4,267 23 4,226 19 7,998 20 7,912 19 9 5 * Arkansas 25 23 * 26 64 24 54 17 35 17 32 185 83 189 77 3,030 42 3,217 35 * 8,619 25 8,652 23 * 26 9 * California 22 20 * 20 87 19 88 15 21 15 18 167 55 163 50 4,752 24 4,616 19 * 8,310 22 8,346 20 * 20 6 Colorado 16 14 * 10143 9117 * 14 16 15 ** 15 173 50 171 46 4,457 19 4,689 16 7,460 16 7,415 14 * 10 3 * Connecticut 19 20 16144 14126 16 26 17 * 24 189 75 193 69 5,209 39 5,246 33 * 8,936 20 9,014 19 16 8 Delaware 20 20 19 — 16 * — 16 27 16 29 159 68 166 69 4,439 40 4,388 38 8,514 20 8,753 20 19 3 ** District of Columbia — 19 — — 19 — 18 37 16 ** 35 248 — 265 * 67 3,576 55 3,630 43 ** 8,887 — 8,633 19 — 0 Florida 22 22 23145 22157 15 28 16 * 29 179 68 185 72 4,459 34 4,523 30 10,597 22 10,434 22 23 7 * Georgia 21 20 19 88 17 87 16 31 17 * 29 201 73 192 70 4,761 33 3,310 27 ** * 8,743 21 8,665 20 19 0 Hawaii — 12 — 52 5 66 14 13 14 12 131 41 129 35 3,031 12 3,513 10 * 5,408 — 5,592 12 — 5 Idaho 14 14 11 — 12 — 14 17 14 15 162 45 170 42 3,702 17 3,734 15 7,198 14 7,365 14 11 8 ** Illinois 23 20 * 22117 20110 16 31 16 28 192 73 188 73 4,489 51 4,649 38 ** 9,219 23 9,118 20 * 22 2 * Indiana 20 18 * 19105 17 78 * 16 35 17 * 32 200 77 195 73 4,826 40 4,946 32 * 9,045 20 8,991 18 * 19 8 * Iowa17 16 15 69 15 56 16 24 17 ** 22 184 64 185 59 3,817 33 4,035 28 * 7,496 17 7,638 16 15 2 * Kansas 19 18 20144 19128 17 27 18 * 26 173 71 175 65 3,965 37 4,052 32 * 8,586 19 8,697 18 20 7 ** Kentucky 22 20 * 24167 21117 * ** 18 51 18 * 46 * 219100 223 92 * 4,015 50 4,326 37 ** 9,167 22 9,075 20 * 24 2 * Louisiana 26 25 30232 27145 * ** 16 44 16 41 236 97 228 90 * 3,852 40 3,874 32 * 10,868 26 10,616 25 30 7 Maine 17 16 12 72 12 — 16 26 17 ** 25 233 65 219 * 60 4,261 31 4,333 27 7,606 17 7,769 16 12 0 ** Maryland 22 20 * 17132 16123 17 29 16 ** 29 193 69 187 65 3,603 49 3,638 40 ** 8,472 22 8,772 20 * 17 5 * Massachusetts 19 19 14182 13126 ** 16 30 17 ** 28 209 80 195 * 77 4,439 41 4,522 35 * 9,041 19 8,892 19 14 6 * Michigan 23 21 * 18 97 17 88 16 34 16 34 214 73 213 74 3,852 42 3,837 36 * 9,565 23 9,551 21 * 18 4 Minnesota 17 16 7 70 7 57 16 20 17 * 19 181 55 175 53 4,450 18 4,609 14 7,225 17 7,497 16 7 1 * Mississippi 24 22 * 29 — 28 — 17 42 17 40 231 91 226 91 3,795 48 3,413 41 * * 10,046 24 9,885 22 * 29 2 * Missouri 22 20 * 20150 19127 * 16 31 16 30 197 73 199 69 4,002 37 3,933 32 * 8,698 22 8,735 20 * 20 1 Montana 13 13 12 65 12 53 15 21 16 * 18 158 — 162 51 4,291 25 4,333 21 6,585 13 6,672 13 12 8 * Nebraska 16 15 16 58 16 43 16 24 17 ** 23 153 63 150 58 4,379 33 4,517 28 * 8,062 16 8,172 15 16 3 Nevada 23 22 20 98 19107 15 25 16 * 22 165 60 159 55 4,048 26 4,017 23 8,328 23 8,404 22 20 1 New Hampshire 16 17 14 — 14 — 17 23 17 22 192 64 180 * 65 5,121 34 5,189 31 7,618 16 7,686 17 14 0 * New Jersey 24 22 * 21149 20151 16 27 16 27 170 73 164 69 4,750 47 4,822 40 * 9,556 24 9,560 22 * 21 9 New Mexico 18 18 13 — 15 — 15 23 15 21 170 59 178 56 3,996 22 3,920 19 6,791 18 6,938 18 13 8 * New York 23 21 * 17221 14226 * 17 29 17 25 * 173 73 168 66 * 5,057 36 5,019 28 * 8,977 23 8,959 21 * 17 7 * North Carolina 18 * 20 18109 16112 16 29 16 28 197 67 205 64 4,346 35 4,201 27 * 8,158 20 8,271 18 * 18 8 * North Dakota 14 * 16 15 — 14 48 15 24 17 ** 22 187 65 172 * 61 4,126 35 4,438 28 * 7,529 16 7,724 14 * 15 7 * Ohio21 20 15143 13125 16 38 16 36 219 82 218 75 * 4,235 34 4,333 27 * 9,492 21 9,326 20 15 2 * Oklahoma 23 21 * 24139 23136 16 38 16 34 * 211 80 216 72 * 4,159 40 4,230 32 * 9,182 23 9,229 21 * 24 4 Oregon 17 16 8 40 9 39 14 17 15 ** 17 162 48 158 45 4,469 15 4,743 14 6,300 17 6,510 16 8 6 * Pennsylvania 19 * 21 16187 14166 * 17 31 17 28 187 74 180 69 4,303 31 4,520 26 * 9,391 21 9,202 19 * 16 6 Rhode Island 20 21 10139 9 — 15 27 16 ** 28 188 66 200 * — 3,869 28 3,929 26 8,557 21 8,620 20 10 8 * South Carolina 20 20 20138 19124 16 27 16 26 176 65 174 61 — 33 — 28 * 8,529 20 8,457 20 20 5 * South Dakota 14 15 15 72 16 46 * 17 22 16 ** 21 168 — 149 * 60 4,741 31 4,918 25 * 7,204 15 7,418 14 15 9 * Tennessee 21 19 * 22 98 19 * 69 * 17 37 17 34 200 84 193 77 * 4,039 37 3,969 29 * 9,197 21 9,019 19 * 22 7 * Texas 22 20 * 23104 21 90 15 31 15 30 186 76 188 72 4,917 34 5,014 27 * 10,135 22 10,142 20 * 23 5 Utah14 14 11 80 11 68 14 17 14 15 147 42 145 39 4,252 17 4,343 15 8,011 14 7,980 14 11 6 * Vermont 16 15 15 33 14 27 16 — 16 20 187 65 166 * — 4,897 31 4,821 26 * 6,816 16 6,898 15 15 2 * Virginia 21 20 20107 18 87 * 17 27 17 24 193 71 183 62 * 4,085 40 4,142 32 * 8,000 21 7,925 20 20 0 Washington 16 17 13 77 11 62 15 18 15 17 157 49 162 46 4,524 23 4,357 20 7,106 17 7,125 16 13 5 ** West Virginia 20 * 23 19110 17 86 * 18 50 18 42 ** 226 98 230 81 ** 5,273 46 5,073 35 ** 8,637 23 8,521 20 * 19 1 * Wisconsin 17 16 12 78 12 73 16 22 16 21 182 60 182 57 5,678 26 5,785 21 * 7,615 17 7,640 16 12 8 Wyoming 15 14 13 92 16 * 99 17 — 17 — 169 — 165 — 5,724 32 5,746 28 6,818 15 6,866 14 13 4 Change 20 6 11 21 4 8 9 3 34 1 20 4 States Improved 20 5 11 4 4 6 9 2 34 0 20 0 States Worsened0 1 0 17 0 2 0 1 0 1 0 xclude prescription drug costs a change of at least 0.5 standard deviations. ** Denotes a estimates reflect only the age 65+ Medicare fee-for-service population.prescription drug costs and are adjusted fo Notes: * Denotes and are adjusted for regional wage differences; Medicare change of 1.0 standard deviation or more. Spending estimates exclude — Indicates that estimates are not available. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. Spending estimates exclude prescription drug costs and are adjusted for regional wage differences; Medicare estimates reflect only the age 65+ fee-for-service Medicare population. — Indicates that estimates are not available. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 38 APPENDIX F1. Healthy Lives: Dimension and Indicator Ranking Overall performance Appendix Exhibit F1. Healthy Lives: Dimension and Indicator Ranking Top quartile Second quartile 00 la are e re n) ,0 or d r pu h c Third quartile fo to e te tio 00 r m liv pe be la gh po lt 0 r1 or 00 0 0 ea -re n) s ( st ei Bottom quartile 00 n) pe x 00 h 0, tio th lo w th si 1, tio s ( 0, to 10 er la ea e ife al st er es la th Data not available ov 10 le e he pu r d er lo ll e (p ob pu ea er nab ok n) (p tia e po ce ve or ity ar po d e sm tio s en po 0 an ha sp e ar e cer la ath al e ho th am 75 t lif 00 c hs ort ity h ho ho h o po es w m an 0, tal pu de al it et h of ea y qu ts w w w te ts w bi m ob n ag s of fe st c (d alit 10 rec po e re ) ts ts id nt al ild t ul ul ul ul ea ar lo ic or fa e rt Ad Ad Ad Ad Ch Co Su Ye Br In M 1 Connecticut 1 1 1 1 1 1 2 1 1 2 1 1 Minnesota 1 1 1 1 1 1 1 2 1 1 1 3 Massachusetts 1 1 1 1 1 1 2 1 1 3 2 4 Utah 1 2 2 1 4 2 1 1 1 1 1 5 California 2 1 2 1 1 1 3 1 1 2 1 5 Colorado 1 1 1 1 4 1 2 2 1 1 1 5 Hawaii 2 1 1 2 2 3 1 1 1 1 1 5 Vermont 1 1 1 2 4 1 1 2 1 1 2 9 New Jersey 2 1 3 2 1 1 2 1 1 1 2 9 Washington 1 1 2 1 3 1 3 1 1 1 1 11 New York 2 1 2 2 1 1 2 1 1 3 2 11 Rhode Island 1 1 1 2 1 3 3 1 2 2 1 13 New Hampshire 1 1 3 1 3 2 1 2 1 1 2 14 Idaho 2 2 2 1 4 2 2 1 2 2 1 14 Iowa 2 2 2 3 2 1 1 3 3 2 2 16 Oregon 1 2 2 1 4 1 4 2 2 1 1 16 Wisconsin 2 2 2 2 2 3 2 2 2 2 2 18 Nebraska 1 2 3 4 2 2 1 2 3 2 1 18 Wyoming 2 3 1 1 4 1 2 3 2 1 2 20 Florida 3 3 2 2 2 2 3 2 2 2 3 20 Maryland 3 2 4 3 1 3 1 1 2 3 2 20 North Dakota 2 2 1 3 3 2 1 3 3 4 1 20 Virginia 3 2 4 2 2 3 1 2 2 2 2 24 Arizona 2 3 2 2 4 2 3 1 2 4 2 24 Illinois 3 2 3 3 1 2 2 1 3 3 1 24 Texas 3 2 2 2 1 2 2 1 4 4 1 27 Maine 1 2 1 1 3 4 3 3 2 2 3 27 Pennsylvania 3 3 3 3 2 3 2 3 2 1 2 29 Montana 2 3 2 3 4 2 3 3 1 2 3 30 Delaware 3 3 3 2 2 3 3 2 2 3 3 30 Kansas 3 2 2 3 3 3 2 3 4 2 2 30 South Dakota 2 3 1 4 3 3 1 3 3 1 2 33 District of Columbia 4 4 4 4 1 3 1 2 1 4 1 34 Alaska 2 3 4 4 4 2 2 3 2 2 2 34 New Mexico 3 4 1 2 4 2 4 3 3 3 2 36 Nevada 3 3 3 4 4 2 3 3 2 3 1 37 North Carolina 3 3 3 2 2 4 3 3 3 3 3 38 Michigan 3 3 4 3 2 4 3 4 3 3 2 38 Ohio 3 3 4 4 2 4 2 4 2 3 3 40 Georgia 4 3 4 3 2 4 3 3 3 4 3 41 Missouri 4 4 4 3 3 3 3 4 4 2 3 42 Indiana 3 4 3 4 3 4 3 4 3 3 4 43 South Carolina 4 4 4 3 3 4 3 3 4 4 4 43 Tennessee 4 4 3 3 2 4 4 4 4 3 4 45 Alabama 4 4 3 3 3 4 4 4 4 4 4 45 Kentucky 4 4 3 4 3 3 4 4 4 4 4 45 Oklahoma 4 4 3 4 4 3 4 4 4 3 4 48 Arkansas 4 4 4 4 3 4 4 4 4 3 4 48 Louisiana 4 4 4 4 3 4 4 4 4 4 4 50 Mississippi 4 4 4 4 1 4 4 4 4 4 4 50 West Virginia 4 4 4 4 4 4 4 4 4 3 4 commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 39 APPENDIX F2. Healthy Lives: Dimension Ranking and Indicator Rates Appendix Exhibit F2. Healthy Lives: Dimension Ranking and Indicator Rates Breast cancer deaths Colorectal cancer Infant morta Mortality amenable to Years of potential life lost per 100,000 female deaths per 100,000 Suicide deaths per deaths per 1,0 health care before age 75 population population 100,000 population births 2011-12 2013-14 2012 2014 2012 2014 2012 2014 2012 2014 2012 2 United States 84.0 84.2 6,412 6,447 21.4 20.6 14.9 14.3 12.6 13.0 6.0 Alabama 109.7 110.7 9,324 9,361 22.9 20.9 * 16.7 15.5 * 14.7 14.5 8.9 Alaska 72.0 72.4 7,194 7,408 17.6 23.8 ** 15.6 15.8 23.1 22.0 5.1 Arizona 72.4 73.1 6,609 6,623 19.1 19.1 13.1 13.2 17.3 18.0 5.8 Arkansas 117.8 121.5 8,928 8,984 23.3 22.6 17.7 16.3 * 16.3 17.3 7.1 California 72.4 70.9 5,108 5,022 21.1 20.0 13.6 13.0 10.0 10.5 4.5 Colorado 61.0 61.5 5,538 5,625 20.3 18.4 * 12.6 12.4 19.7 19.9 4.6 Connecticut 62.0 59.7 5,146 4,986 19.2 17.6 * 12.1 11.5 9.9 9.8 5.3 Delaware 84.6 84.4 7,204 6,817 22.7 21.3 * 13.4 13.5 13.2 13.2 7.6 District of Columbia 123.3 125.2 7,831 7,601 31.1 28.9 * 12.8 18.9 ** 5.7 7.8 * 7.9 Florida 80.3 80.3 6,556 6,575 20.6 19.7 13.8 13.3 14.3 13.9 6.1 Georgia 99.3 102.7 6,966 7,278 21.6 22.7 15.1 15.7 11.7 12.6 6.2 Hawaii 71.4 76.1 5,445 5,369 16.3 16.7 13.6 13.9 13.1 13.8 4.9 Idaho 64.8 67.9 5,809 6,112 15.8 20.4 ** 14.2 12.8 * 19.0 20.0 5.4 Illinois 88.7 87.2 6,161 6,125 23.0 21.9 16.0 15.0 * 9.8 10.5 6.5 Indiana 92.0 91.5 7,342 7,528 21.8 21.0 16.4 16.2 14.3 14.3 6.7 Iowa 72.0 72.0 5,747 5,701 20.3 19.3 15.9 15.5 12.7 12.9 5.3 Kansas 77.9 79.0 6,643 6,541 23.0 19.1 ** 14.7 15.1 17.5 15.7 6.3 Kentucky 107.9 106.0 8,869 8,844 23.4 20.9 ** 17.1 17.4 16.2 16.0 7.2 Louisiana 120.3 126.6 8,952 9,192 24.4 24.2 17.7 18.1 12.4 14.3 * 8.1 Maine 61.7 64.6 6,128 6,251 17.3 16.8 14.2 11.9 ** 14.5 15.7 7.0 Maryland 89.1 90.2 6,244 6,268 23.7 22.9 15.0 14.6 9.5 9.8 6.4 Massachusetts 61.2 60.3 4,892 5,283 19.5 17.9 * 13.4 12.6 8.7 8.2 4.2 Michigan 91.9 92.2 6,977 7,039 22.3 22.4 14.5 14.6 12.5 13.3 6.9 Minnesota 56.5 54.3 4,910 4,892 18.1 17.1 13.2 12.7 12.0 12.2 5.0 Mississippi 132.6 140.8 9,610 9,917 25.3 23.8 * 19.4 19.3 14.0 12.5 8.9 Missouri 95.5 95.4 7,487 7,506 22.5 22.1 16.6 14.7 ** 14.9 16.3 6.6 Montana 67.9 71.8 6,963 6,640 20.7 19.3 * 14.3 14.6 22.6 23.9 5.9 Nebraska 64.6 66.8 5,701 5,966 21.2 21.6 16.0 16.1 12.5 13.4 4.7 Nevada 91.9 94.7 6,658 6,854 22.2 22.0 17.7 16.4 * 18.2 19.5 4.9 New Hampshire 58.4 58.5 5,097 5,700 * 19.0 21.2 * 13.7 12.7 * 14.1 17.8 * 4.2 New Jersey 76.7 74.3 5,325 5,286 22.7 21.6 15.9 14.2 * 7.4 8.3 4.4 New Mexico 78.5 80.4 7,998 8,349 18.0 18.8 13.9 13.7 21.3 21.0 6.8 New York 79.9 78.5 5,237 5,131 20.8 19.2 * 14.4 13.5 * 8.3 8.1 5.0 North Carolina 92.9 92.4 7,029 7,084 21.5 21.0 14.5 14.4 12.7 13.0 7.4 North Dakota 68.5 71.3 6,473 6,099 16.9 14.2 ** 13.2 14.9 * 15.2 17.8 * 6.3 Ohio 95.1 94.8 7,282 7,404 22.8 22.6 16.4 15.9 13.0 12.6 7.5 Oklahoma 115.9 123.0 8,915 9,101 23.4 22.0 * 18.1 16.5 * 17.6 19.1 7.5 Oregon 62.3 63.4 5,799 5,905 20.3 20.4 13.8 13.0 17.8 18.6 5.4 Pennsylvania 83.5 82.4 6,726 6,577 22.6 20.8 * 16.0 15.2 12.4 13.3 7.1 Rhode Island 72.0 66.7 5,549 5,570 18.1 18.6 14.4 13.6 9.5 10.0 6.5 South Carolina 99.4 99.8 7,962 8,039 22.3 23.0 15.4 14.7 13.7 15.1 7.5 South Dakota 75.8 73.8 6,873 6,824 19.5 18.3 * 16.4 17.5 * 16.8 17.1 8.3 Tennessee 109.4 112.3 8,464 8,599 22.9 21.6 * 16.9 15.3 * 14.6 14.1 7.2 Texas 92.4 94.8 6,457 6,538 21.1 19.8 * 14.8 14.1 11.9 12.2 5.8 Utah 61.1 61.2 5,719 5,876 20.4 20.3 10.7 11.8 * 21.0 20.5 4.8 Vermont 55.3 57.5 5,102 5,517 19.4 18.1 * 13.5 13.6 13.1 18.7 ** 4.3 Virginia 82.0 81.0 5,965 5,921 21.3 22.7 * 14.5 14.0 12.6 12.9 6.5 Washington 62.7 62.7 5,399 5,394 17.9 20.4 ** 13.2 11.9 * 14.5 15.3 5.3 West Virginia 105.5 105.7 9,474 9,536 22.6 22.4 17.5 18.8 * 17.1 18.1 7.2 Wisconsin 70.0 70.3 5,696 5,764 20.4 19.3 13.8 13.7 12.3 13.1 5.7 Wyoming 71.1 71.7 7,046 7,350 15.7 14.6 15.8 10.9 ** 29.6 20.6 ** 5.6 Change 0 1 23 19 6 States Improved 0 0 18 14 1 States Worsened 0 1 5 5 5 Notes:*Denotesachangeofatleast0.5standarddeviations.**Denotesachangeof1.0standarddeviationormore. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 40 APPENDIX F2. Healthy Lives: Dimension Ranking and Indicator Rates (continued) Appendix Exhibit F2. Healthy Lives: Dimension Ranking and Indicator Rates ncer Infant mortality, Adults with poor Breast cancer deaths Colorectal Children who are cancer Infant morta ,000 Suicide deaths per deaths per amenable to Years of potential life lost Mortality 1,000 live health-related quality per 100,000 female overweight or Adults whoper lost deaths per 100,000 Suicide deaths have deaths per 1,0 n 100,000 population health care births population obese 100,000 population of life age 75 Adults who smoke Adults who are obese before population six or more teeth births 014 2012 2014 2011-12 2012 2013 2013-14 2013 2012 2015 2014 2013 2012 2015 2014 2013 2015 2012 2014 2011/12 2012 2012 20142014 2012 2 14.3 United States13.0 12.6 6.0 84.0 6.084.2 26% 6,412 26% 6,447 18% 21.4 17% 20.629% 29% 14.9 14.331% 12.6 10% 13.0 10% 6.0 15.5 * Alabama 14.7 14.5 109.7 8.9 8.6 110.7 31 9,324 32 9,361 21 22.9 21 20.9 * 33 16.7 ** 37 15.5 35 * 14.7 17 14.5 17 8.9 15.8 Alaska 23.1 22.0 5.1 72.0 5.872.4 * 24 7,194 24 7,408 23 17.6 19 ** 23.8 **28 15.6 29 15.8 30 23.1 9 22.0 9 5.1 13.2 Arizona 17.3 18.0 5.8 72.4 5.373.1 24 6,609 28 **6,623 16 19.1 14 * 19.1 28 13.1 * 30 13.2 37 17.3 10 18.0 9 5.8 16.3 * Arkansas 16.3 17.3 117.8 7.1 7.9 * 121.5 33 8,928 33 8,984 26 23.3 25 22.6 37 17.7 36 16.3 34 * 16.3 17 17.3 17 7.1 13.0 California 10.0 10.5 4.5 72.4 4.870.9 29 5,108 27 * 5,022 12 21.1 11 20.0 25 13.6 25 13.0 30 10.0 7 10.5 7 4.5 12.4 Colorado 19.7 19.9 4.6 61.0 5.161.5 23 5,538 24 5,625 18 20.3 16 * 18.4 * 22 12.6 * 20 12.4 23 19.7 7 19.9 7 4.6 11.5 Connecticut 9.9 9.8 5.3 62.0 4.859.7 21 5,146 23 * 4,986 16 19.2 13 * 17.6 * 25 12.1 25 11.5 30 9.9 8 9.8 8 5.3 13.5 Delaware 13.2 13.2 7.6 84.6 6.484.4 ** 25 7,204 26 6,817 20 22.7 17 * 21.3 * 31 13.4 30 13.5 32 13.2 10 13.2 11 7.6 18.9 ** District of Columbia 5.7 7.8 * 123.3 7.9 6.7 ** 125.2 21 7,831 21 7,601 19 31.1 16 * 28.9 * 23 12.8 * 21 18.9 35 ** 5.7 7 7.8 * 7 7.9 13.3 Florida 14.3 13.9 6.1 80.3 6.180.3 28 6,556 26 * 6,575 17 20.6 16 19.7 27 13.8 27 13.3 28 14.3 11 13.9 11 6.1 15.7 Georgia 11.7 12.6 6.2 99.3 7.0 * 102.7 27 6,966 26 7,278 19 21.6 18 22.7 31 15.1 31 15.7 35 11.7 13 12.6 12 6.2 13.9 Hawaii 13.1 13.8 4.9 71.4 6.476.1 ** 20 5,445 22 * 5,369 13 16.3 14 16.7 23 13.6 24 13.9 27 13.1 6 13.8 7 4.9 12.8 * Idaho19.0 20.0 5.4 64.8 5.667.9 23 5,809 25 * 6,112 17 15.8 14 * 20.4 **30 14.2 29 12.8 28 * 19.0 9 20.0 8 5.4 15.0 * Illinois 9.8 10.5 6.5 88.7 6.087.2 22 6,161 23 6,125 18 23.0 15 * 21.9 30 16.0 31 15.0 34 * 9.8 9 10.5 8 6.5 16.2 Indiana 14.3 14.3 6.7 92.0 7.291.5 26 7,342 28 * 7,528 22 21.8 21 21.0 32 16.4 32 16.2 31 14.3 13 14.3 14 6.7 15.5 Iowa 12.7 12.9 5.3 72.0 4.372.0 * 22 5,747 21 5,701 19 20.3 18 19.3 32 15.9 32 15.5 28 12.7 9 12.9 10 5.3 15.1 Kansas 17.5 15.7 6.3 77.9 6.579.0 23 6,643 24 6,541 20 23.0 18 * 19.1 **31 14.7 ** 35 15.1 30 17.5 10 15.7 9 6.3 17.4 Kentucky 16.2 16.0 107.9 7.2 6.4 * 106.0 32 8,869 32 8,844 26 23.4 26 20.9 **34 17.1 * 36 17.4 36 16.2 16 16.0 18 * 7.2 18.1 Louisiana 12.4 14.3 * 120.3 8.1 8.7 * 126.6 30 8,952 29 9,192 24 24.4 22 * 24.2 33 17.7 ** 37 18.1 40 12.4 17 14.3 * 14 * 8.1 11.9 ** Maine14.5 15.7 7.0 61.7 7.164.6 25 6,128 27 * 6,251 20 17.3 19 16.8 29 14.2 30 11.9 30 ** 14.5 14 15.7 13 7.0 14.6 Maryland 9.5 9.8 6.4 89.1 6.690.2 22 6,244 21 6,268 16 23.7 15 22.9 29 15.0 29 14.6 32 9.5 9 9.8 9 6.4 12.6 Massachusetts 8.2 8.7 4.2 61.2 4.260.3 22 4,892 24 * 5,283 17 19.5 14 * 17.9 * 24 13.4 24 12.6 31 8.7 9 8.2 10 4.2 14.6 Michigan 12.5 13.3 6.9 91.9 7.192.2 28 6,977 27 7,039 21 22.3 21 22.4 32 14.5 32 14.6 33 12.5 11 13.3 10 6.9 12.7 Minnesota 12.0 12.2 5.0 56.5 5.154.3 20 4,910 20 4,892 18 18.1 16 * 17.1 26 13.2 26 12.7 27 12.0 7 12.2 7 5.0 19.3 Mississippi 14.0 12.5 132.6 8.9 9.6 * 140.8 31 9,610 31 9,917 25 25.3 22 * 23.8 * 37 19.4 37 19.3 40 14.0 18 12.5 19 8.9 14.7 ** Missouri 14.9 16.3 6.6 95.5 6.595.4 28 7,487 28 7,506 22 22.5 22 22.1 31 16.6 * 33 14.7 28 ** 14.9 12 16.3 13 6.6 14.6 Montana 22.6 23.9 5.9 67.9 5.671.8 25 6,963 26 6,640 19 20.7 19 19.3 * 25 14.3 24 14.6 29 22.6 11 23.9 11 5.9 16.1 Nebraska 12.5 13.4 4.7 64.6 5.266.8 22 5,701 21 5,966 18 21.2 17 21.6 30 16.0 31 16.1 29 12.5 8 13.4 8 4.7 16.4 * Nevada 18.2 19.5 4.9 91.9 5.394.7 25 6,658 27 * 6,854 19 22.2 18 22.0 27 17.7 28 16.4 33 * 18.2 11 19.5 8 * 4.9 12.7 * New Hampshire 17.8 14.1 * 4.2 58.4 5.658.5 ** 22 5,097 22 5,700 * 16 19.0 16 21.2 * 27 13.7 26 12.7 26 * 14.1 10 17.8 * 10 4.2 14.2 * New Jersey 7.4 8.3 4.4 76.7 4.574.3 22 5,325 23 5,286 16 22.7 14 * 21.6 27 15.9 * 25 14.2 25 * 7.4 9 8.3 10 4.4 13.7 New Mexico 21.3 21.0 6.8 78.5 5.380.4 ** 29 7,998 29 8,349 19 18.0 18 18.8 28 13.9 * 31 13.7 33 21.3 10 21.0 10 6.8 13.5 * New York 8.3 8.1 5.0 79.9 4.978.5 25 5,237 25 5,131 17 20.8 15 * 19.2 * 25 14.4 25 13.5 32 * 8.3 10 8.1 9 5.0 14.4 North Carolina 13.0 12.7 7.4 92.9 7.092.4 27 7,029 26 7,084 20 21.5 19 21.0 30 14.5 31 14.4 31 12.7 13 13.0 13 7.4 14.9 * North Dakota 17.8 15.2 * 6.3 68.5 6.071.3 20 6,473 20 6,099 21 16.9 19 * 14.2 **31 13.2 31 14.9 36 * 15.2 9 17.8 * 7 * 6.3 15.9 Ohio 13.0 12.6 7.5 95.1 7.394.8 26 7,282 24 * 7,404 23 22.8 22 22.6 31 16.4 30 15.9 31 13.0 13 12.6 13 7.5 16.5 * Oklahoma 17.6 19.1 115.9 7.5 6.7 * 123.0 30 8,915 30 9,101 24 23.4 22 * 22.0 * 34 18.1 35 16.5 34 * 17.6 14 19.1 14 7.5 13.0 Oregon 17.8 18.6 5.4 62.3 4.963.4 26 5,799 31 **5,905 17 20.3 17 20.4 27 13.8 * 30 13.0 26 17.8 10 18.6 8 * 5.4 15.2 Pennsylvania 13.3 12.4 7.1 83.5 6.782.4 24 6,726 24 6,577 21 22.6 18 * 20.8 * 30 16.0 30 15.2 26 12.4 11 13.3 10 7.1 13.6 Rhode Island 10.0 9.5 6.5 72.0 6.566.7 25 5,549 26 5,570 17 18.1 15 * 18.6 27 14.4 27 13.6 28 9.5 9 10.0 7 * 6.5 14.7 South Carolina 15.1 13.7 7.5 99.4 6.999.8 * 28 7,962 28 8,039 22 22.3 20 * 23.0 33 15.4 33 14.7 39 13.7 15 15.1 15 7.5 17.5 * South Dakota 17.1 16.8 8.3 75.8 6.573.8 ** 21 6,873 22 6,824 20 19.5 20 18.3 * 30 16.4 31 17.5 27 * 16.8 9 17.1 10 8.3 15.3 * Tennessee 14.6 14.1 109.4 7.2 6.8 112.3 31 8,464 30 8,599 23 22.9 22 21.6 * 35 16.9 35 15.3 34 * 14.6 18 14.1 16 * 7.2 14.1 Texas11.9 12.2 5.8 92.4 5.894.8 24 6,457 25 6,538 16 21.1 15 19.8 * 32 14.8 33 14.1 37 11.9 8 12.2 7 5.8 11.8 * Utah 21.0 20.5 4.8 61.1 5.261.2 20 5,719 21 5,876 10 20.4 9 20.3 24 10.7 24 11.8 22 * 21.0 6 20.5 6 4.8 13.6 Vermont 13.1 18.7 ** 4.3 55.3 4.457.5 22 5,102 22 5,517 17 19.4 16 18.1 * 25 13.5 25 13.6 25 13.1 11 18.7 **10 4.3 14.0 Virginia 12.6 12.9 6.5 82.0 6.281.0 23 5,965 22 5,921 19 21.3 17 * 22.7 * 27 14.5 * 29 14.0 30 12.6 11 12.9 10 6.5 11.9 * Washington 14.5 15.3 5.3 62.7 4.562.7 * 28 5,399 27 5,394 16 17.9 15 20.4 **27 13.2 26 11.9 26 * 14.5 8 15.3 8 5.3 18.8 * West Virginia 18.1 17.1 105.5 7.2 7.6 105.7 34 9,474 34 9,536 27 22.6 26 22.4 37 17.5 37 18.8 34 * 17.1 23 18.1 22 7.2 13.7 Wisconsin 12.3 13.1 5.7 70.0 6.370.3 * 24 5,696 23 5,764 19 20.4 17 * 19.3 29 13.8 30 13.7 29 12.3 11 13.1 10 5.7 10.9 ** Wyoming 29.6 20.6 ** 5.6 71.1 4.871.7 * 23 7,046 25 * 7,350 21 15.7 19 * 14.6 29 15.8 30 10.9 27 ** 29.6 11 20.6 **10 5.6 19 Change 6 18 0 13 1 23 23 12 19 6 7 14 States Improved 1 10 0 3 0 23 18 3 14 1 6 5 States Worsened 5 8 0 10 1 0 5 9 5 5 1 Notes:*Denotesachangeofatleast0.5standarddeviations.**Denotesachangeof1.0standarddeviationormore. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 41 APPENDIX F3. MortalityMortality AmenableCare by Race, Deaths per 100,000 population, 2011–12 & 2013–14 -12 & 2013-14 Appendix Exhibit F3. Amenable to Health to Health Care by Race, Deaths per 100,000 population, 2011 White Black Hispanic Change in 2017 Change in 2017 Change in 2017 2011-12 2013-14 rate ranking 2011-12 2013-14 rate ranking 2011-12 2013-14 rate ranking United States 77.6 78.2 0.6 — 157.0 155.0 -2.0 — 66.3 66.5 0.2 — Alabama 95.1 96.7 1.6 43 166.2 165.4 -0.8 35 46.5 41.3 -5.2 8 Alaska 63.7 61.8 -1.9 9 87.1 95.9 8.8 3 — 40.2 — 6 Arizona 69.6 71.0 1.4 23 127.8 127.5 -0.3 11 67.7 67.6 -0.1 36 Arkansas 109.3 112.7 3.4 49 199.6 198.3 -1.3 43 53.8 52.9 -0.9 19 California 71.8 70.6 -1.2 22 151.5 145.9 -5.6 20 65.4 65.3 -0.1 34 Colorado 57.4 58.4 1.0 5 121.6 111.3 -10.3 10 70.7 71.6 0.9 37 Connecticut 57.7 55.4 -2.3 3 108.7 103.7 -5.0 5 61.8 61.7 -0.1 32 Delaware 76.2 75.9 -0.3 31 130.7 129.3 -1.4 13 43.9 57.8 13.9 28 District of Columbia 42.7 41.8 -0.9 1 183.6 189.1 5.5 40 39.5 50.4 10.9 16 Florida 77.4 78.2 0.8 33 138.6 137.6 -1.0 16 55.9 55.2 -0.7 22 Georgia 84.7 88.5 3.8 40 152.6 153.5 0.9 26 38.0 39.3 1.3 2 Hawaii 58.7 64.9 6.2 13 74.1 106.3 32.2 8 94.1 76.5 -17.6 40 Idaho 65.7 69.0 3.3 20 — — — — 44.1 56.1 12.0 25 Illinois 77.6 77.3 -0.3 32 182.4 177.0 -5.4 37 60.6 59.4 -1.2 30 Indiana 88.2 87.0 -1.2 38 156.8 159.9 3.1 30 62.4 60.7 -1.7 31 Iowa 71.0 71.0 0.0 23 152.3 146.4 -5.9 22 42.9 45.4 2.5 10 Kansas 75.3 75.8 0.5 29 141.8 155.7 13.9 28 59.7 62.7 3.0 33 Kentucky 105.6 104.3 -1.3 47 161.7 153.8 -7.9 27 41.3 40.6 -0.7 7 Louisiana 99.4 103.2 3.8 45 183.6 193.3 9.7 41 34.6 49.0 14.4 15 Maine 62.1 65.0 2.9 14 67.1 102.7 35.6 4 — — — — Maryland 75.1 78.5 3.4 34 138.3 135.2 -3.1 14 37.9 39.8 1.9 3 Massachusetts 59.9 60.6 0.7 8 98.1 82.6 -15.5 1 56.1 53.1 -3.0 20 Michigan 78.7 79.4 0.7 35 188.7 188.0 -0.7 39 76.1 77.7 1.6 41 Minnesota 54.5 51.0 -3.5 2 94.3 104.2 9.9 6 44.0 45.5 1.5 11 Mississippi 104.3 113.9 9.6 50 195.8 199.7 3.9 44 45.7 48.6 2.9 14 Missouri 88.3 89.3 1.0 41 173.4 163.4 -10.0 33 50.8 57.1 6.3 27 Montana 63.5 67.8 4.3 18 — — — — 56.5 — — — Nebraska 62.3 65.1 2.8 15 137.0 135.7 -1.3 15 40.9 47.8 6.9 12 Nevada 96.1 99.8 3.7 44 148.7 150.6 1.9 25 59.7 65.3 5.6 34 New Hampshire 59.7 59.6 -0.1 6 — — — — — — — — New Jersey 72.1 70.3 -1.8 21 147.6 144.4 -3.2 19 58.4 53.6 -4.8 21 New Mexico 72.0 75.8 3.8 29 120.4 128.7 8.3 12 82.2 80.9 -1.3 43 New York 71.8 71.1 -0.7 25 142.4 138.9 -3.5 17 74.3 71.9 -2.4 38 North Carolina 80.4 81.1 0.7 36 153.8 148.2 -5.6 24 37.5 40.1 2.6 5 North Dakota 63.6 67.0 3.4 17 — — — — — — — — Ohio 87.5 87.8 0.3 39 168.8 162.4 -6.4 32 57.6 55.8 -1.8 24 Oklahoma 111.4 117.5 6.1 51 184.0 195.6 11.6 42 83.4 78.2 -5.2 42 Oregon 63.3 64.0 0.7 11 119.7 106.6 -13.1 9 45.9 50.7 4.8 17 Pennsylvania 76.0 74.9 -1.1 28 166.7 160.7 -6.0 31 67.8 75.6 7.8 39 Rhode Island 72.1 68.7 -3.4 19 116.4 83.1 -33.3 2 49.8 44.4 -5.4 9 South Carolina 82.9 83.5 0.6 37 156.6 156.2 -0.4 29 41.7 51.7 10.0 18 South Dakota 68.2 65.4 -2.8 16 — — — — — — — — Tennessee 100.7 103.4 2.7 46 177.3 181.7 4.4 38 45.7 40.0 -5.7 4 Texas 86.6 89.7 3.1 42 167.0 165.0 -2.0 34 83.9 86.7 2.8 44 Utah 60.1 60.0 -0.1 7 132.7 146.7 14.0 23 56.4 55.6 -0.8 23 Vermont 55.5 58.1 2.6 4 — — — — — — — — Virginia 72.2 72.8 0.6 27 141.2 139.1 -2.1 18 37.4 35.5 -1.9 1 Washington 62.1 62.4 0.3 10 109.8 105.3 -4.5 7 49.6 48.5 -1.1 13 West Virginia 104.4 105.7 1.3 48 174.3 146.0 -28.3 21 — — — — Wisconsin 65.0 64.3 -0.7 12 160.8 173.3 12.5 36 47.8 57.0 9.2 26 Wyoming 69.5 71.4 1.9 26 — — — — 72.8 58.8 -14.0 29 Notes: — Indicates that estimates are not available. Notes: — Indicates that estimates are not available. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 42 APPENDIX G1. Equity: Dimension and Subdimension Ranking Appendix Exhibit G1. Equity: Dimension and Subdim Overall performance Top quartile Income Race/Ethnicity Second quartile subdimension subdimension Third quartile 1 Hawaii 1 1 Bottom quartile 2 Rhode Island 1 1 Data not available 2 Vermont 1 1 4 Massachusetts 1 1 5 Minnesota 1 1 6 New Hampshire 1 1 6 New York 1 1 8 Colorado 1 1 8 Connecticut 1 1 10 California 2 1 10 Iowa 1 2 10 Washington 1 2 13 District of Columbia 2 1 13 Maryland 2 1 15 New Mexico 2 2 16 Nebraska 2 2 16 New Jersey 2 2 18 Maine 2 2 18 South Dakota 1 3 18 Utah 2 2 21 Arizona 3 2 21 Delaware 2 3 21 North Dakota 2 2 21 Virginia 3 2 25 Illinois 2 3 25 Oregon 2 3 27 Wisconsin 1 4 28 Idaho 3 3 28 Pennsylvania 2 3 30 Alaska 4 2 31 Kansas 3 3 32 West Virginia 3 3 33 Florida 4 2 33 Michigan 3 3 33 Missouri 4 2 33 Montana 3 4 37 North Carolina 3 3 37 Ohio 3 3 37 Texas 3 3 40 Georgia 4 3 40 Tennessee 3 3 40 Wyoming 3 3 43 Kentucky 3 4 44 Louisiana 4 4 44 Nevada 3 4 46 Alabama 4 4 47 Oklahoma 4 4 48 Arkansas 4 4 48 Indiana 4 4 48 South Carolina 4 4 51 Mississippi 4 4 commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 43 APPENDIX G2. Equity: Change in Equity Dimension Performance by Indicator Appendix Exhibit G2. Equity: Change in Equity Dimension Performance by Indicator Number of states where Equity for the disparate population: Equity Subdimension and Indicator • Improveda • No Changeb • Worseneda Income 0 Uninsured ages 19–64 46 50 Adults who went without care because of cost in past year 30 15 6 At risk adults without a doctor visit 25 11 15 Adults without a dental visit in past year 16 12 23 Adults without a usual source of care 25 12 14 Adults without age- and gender-appropriate cancer screenings 30 14 7 Adults without age-appropriate vaccines 28 16 7 Children ages 19–35 months without all recommended vaccines 21 11 19 Elderly patients who received a high-risk prescription drug 25 25 1 Medicare admissions for ambulatory care–sensitive conditions 44 4 3 Medicare 30-day hospital readmissions, per 1,000 beneficiaries 37 13 1 Potentially avoidable ED visits among Medicare beneficiaries, per 1,000 beneficiaries 18 6 27 Adults with poor health-related quality of life 18 5 28 Adults who smoke 18 17 16 Adults who are obese 14 7 30 Adults who have lost six or more teeth 25 8 18 Race/Ethnicity Uninsured ages 19–64 35 15 1 Adults who went without care because of cost in past year 23 16 12 At risk adults without a doctor visit 23 8 20 Adults without a dental visit in past year 11 11 29 Adults without a usual source of care 19 14 18 Adults without age- and gender-appropriate cancer screenings 18 8 25 Adults without age-appropriate vaccines 19 9 23 Children ages 19–35 months without all recommended vaccines 14 23 14 Mortality amenable to health care 30 2 19 Infant mortality, deaths per 1,000 live births 30 12 9 Adults with poor health-related quality of life 17 2 32 Adults who smoke 21 13 17 Adults who are obese 17 10 24 Adults who have lost six or more teeth 24 11 16 Notes: Selected indicators only. Trend data generally reflect the two-year period ending in 2014 or 2015—refer to Appendix Exhibit A1 for additional detail. (a) Improvement indicates that the equity gap between states' vulnreable population and the U.S. average narrowed and that the rate among the states' vulnerable population improved. Worsening indicates that the equity gap between states' vulnerable population and the U.S. average widened and that the rate among the states' vulnerable population got worse. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. Notes: Selected indicators only. Trend data generally reflect the two-year period ending in 2014 or 2015—refer to Appendix A1 for additional detail. (a) Improvement indicates that the equity gap between states’ vulnreable population and the U.S. average narrowed and that the rate among the states’ vulnerable population improved. Worsening indicates that the equity gap between states’ vulnerable population and the U.S. average widened and that the rate among the states’ vulnerable population got worse. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 44 APPENDIX G3. Equity: Summary ofSummary of Indicator Change Over Time Appendix Exhibit G3. Equity: Indicator Change Over Time Total Race/Ethnicity Income Number of Number of Percent of Number of Number of Percent of Number of Number of Percent of indicators indicators indicators indicators indicators indicators indicators indicators indicators improved with data improved improved with data improved improved with data improved Alabama 11 29 38% 4 13 31% 7 16 44% Alaska 12 30 40% 4 14 29% 8 16 50% Arizona 18 31 58% 8 14 57% 10 17 59% Arkansas 19 31 61% 10 14 71% 9 17 53% California 20 31 65% 10 14 71% 10 17 59% Colorado 17 30 57% 7 13 54% 10 17 59% Connecticut 16 30 53% 6 14 43% 10 16 63% Delaware 13 30 43% 5 14 36% 8 16 50% District of Columbia 16 30 53% 7 14 50% 9 16 56% Florida 15 31 48% 9 14 64% 6 17 35% Georgia 18 31 58% 7 14 50% 11 17 65% Hawaii 11 29 38% 4 13 31% 7 16 44% Idaho 14 28 50% 5 12 42% 9 16 56% Illinois 15 31 48% 7 14 50% 8 17 47% Indiana 15 30 50% 6 13 46% 9 17 53% Iowa 16 30 53% 8 13 62% 8 17 47% Kansas 13 31 42% 6 14 43% 7 17 41% Kentucky 17 30 57% 6 13 46% 11 17 65% Louisiana 15 29 52% 4 12 33% 11 17 65% Maine 4 27 15% 1 11 9% 3 16 19% Maryland 17 31 55% 8 14 57% 9 17 53% Massachusetts 14 30 47% 6 13 46% 8 17 47% Michigan 15 31 48% 7 14 50% 8 17 47% Minnesota 14 30 47% 4 13 31% 10 17 59% Mississippi 12 30 40% 4 14 29% 8 16 50% Missouri 14 30 47% 8 13 62% 6 17 35% Montana 15 30 50% 9 14 64% 6 16 38% Nebraska 11 31 35% 4 14 29% 7 17 41% Nevada 10 31 32% 2 14 14% 8 17 47% New Hampshire 16 26 62% 6 10 60% 10 16 63% New Jersey 16 31 52% 8 14 57% 8 17 47% New Mexico 10 30 33% 3 14 21% 7 16 44% New York 22 31 71% 8 14 57% 14 17 82% North Carolina 18 31 58% 7 14 50% 11 17 65% North Dakota 14 29 48% 7 13 54% 7 16 44% Ohio 10 30 33% 4 13 31% 6 17 35% Oklahoma 19 31 61% 10 14 71% 9 17 53% Oregon 18 30 60% 7 13 54% 11 17 65% Pennsylvania 11 30 37% 2 14 14% 9 16 56% Rhode Island 20 30 67% 9 14 64% 11 16 69% South Carolina 13 31 42% 5 14 36% 8 17 47% South Dakota 14 31 45% 6 14 43% 8 17 47% Tennessee 14 28 50% 4 11 36% 10 17 59% Texas 13 31 42% 6 14 43% 7 17 41% Utah 11 28 39% 4 11 36% 7 17 41% Vermont 12 24 50% 4 8 50% 8 16 50% Virginia 18 31 58% 8 14 57% 10 17 59% Washington 15 31 48% 5 14 36% 10 17 59% West Virginia 14 29 48% 3 12 25% 11 17 65% Wisconsin 11 30 37% 3 13 23% 8 17 47% Wyoming 11 28 39% 6 12 50% 5 16 31% commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 45 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes 1. Percent of adults ages 19–64 uninsured: Authors’ analysis of 2013 2013, 2015). and 2015 1-year American Community Survey (ACS) Public Use 10. Percent of children with a medical home: Percent of children Micro Sample (PUMS) (U.S. Census Bureau, ACS PUMS 2013, 2015). ages 0–17 who have a personal doctor or nurse, have a usual 2. Percent of children ages 0–18 uninsured: Authors’ analysis of 2013 source for sick and well care, receive family-centered care, have and 2015 1-year American Community Survey (ACS) Public Use no problems getting needed referrals, and receive effective care Micro Sample (PUMS) (U.S. Census Bureau, ACS PUMS 2013, 2015). coordination when needed. For more information, see www. childhealthdata.org. Authors’ analysis of 2011/12 National Survey of 3. Percent of adults who went without care because of cost in the Children’s Health (CAHMI, NSCH 2011/12). past year: Percent of adults age 18 and older who reported a time in the past 12 months when they needed to see a doctor but could not 11. Percent of children with a medical and dental preventive care because of cost. Authors’ analysis of 2013 and 2015 Behavioral Risk visit in the past year: Percent of children ages 0–17 with a preventive Factor Surveillance System (CDC, BRFSS 2013, 2015). medical visit and, if ages 1–17, a preventive dental visit in the past year. For more information, see www.childhealthdata.org. Authors’ 4. Percent of individuals under age 65 with high out-of-pocket analysis of 2011/12 National Survey of Children’s Health (CAHMI, medical costs relative to their annual household income: Out-of- NSCH 2011/12). pocket medical expenses equaled 10 percent or more of income, or 5 percent or more of income if low-income (under 200% of federal 12. Percent of children with emotional, behavioral, or poverty level), not including health insurance premiums. Ougni developmental problems who received needed mental health care Chakraborty, Robert F. Wagner School of Public Service, New York in the past year: Percent of children ages 2–17 who had any kind of University, analysis of 2014 and 2016 Current Population Survey emotional, developmental, or behavioral problem that required (representing respondents’ experiences in 2013 and 2015), Annual treatment or counseling and who received treatment from a mental Social and Economic Supplement (U.S. Census Bureau, CPS ASES health professional (as defined) during the past 12 months. For 2014, 2016). more information, see www.childhealthdata.org. Authors’ analysis of 2011/12 National Survey of Children’s Health (CAHMI, NSCH 5. Percent of at-risk adults without a routine doctor visit in the 2011/12). past two years: Percent of adults age 50 and older, or in fair or poor health, or ever told they have diabetes or pre-diabetes, acute 13. Percent of children ages 19–35 months who received all myocardial infarction, heart disease, stroke, or asthma who did not recommended doses of seven key vaccines: Percent of children visit a doctor for a routine checkup in the past two years. Authors’ ages 19–35 months who received at least 4 doses of diphtheria, analysis of 2013 and 2015 Behavioral Risk Factor Surveillance System tetanus, and accellular pertussis (DTaP/DT/DTP) vaccine; at least 3 (CDC, BRFSS 2013, 2015). doses of poliovirus vaccine; at least 1 dose of measles-containing vaccine (including mumps-rubella (MMR) vaccine); full series of 6. Percent of adults without a dental visit in the past year: Percent Haemophilus influenza type b (Hib) vaccine (3 or 4 doses depending of adults age 18 and older who did not visit a dentist or dental clinic on product type); at least 3 doses of hepatitis B vaccine (HepB); at within the past year. Authors’ analysis of 2012 and 2014 Behavioral least 1 dose of varicella vaccine; and at least 4 doses of pneumococcal Risk Factor Surveillance System (CDC, BRFSS 2012, 2014). conjugate vaccine (PCV). Data from the 2013–2015 National 7. Percent of adults with a usual source of care: Percent of adults age Immunization Survey (NIS) Public Use Files (NCHS, NIS 2013, 2014, 18 and older who have one (or more) person they think of as their 2015) (2013 and 2014 data used for stratification by income and race/ personal health care provider. Authors’ analysis of 2013 and 2015 ethnicity for equity analysis). Behavioral Risk Factor Surveillance System (CDC, BRFSS 2013, 2015). 14. Percent of Medicare beneficiaries who received at least one 8. Percent of adults with age- and gender-appropriate drug that should be avoided in the elderly: Percent of fee-for- cancer screenings: Percent of adults ages 50–74 who received service Medicare beneficiaries age 65 and older who received at sigmoidoscopy or colonoscopy in the past 10 years or a fecal occult least one drug from a list of 13 classes of high-risk prescriptions that blood test in the past two years; a mammogram in the past two should be avoided by the elderly. Y. Zhang, University of Pittsburgh, years (women ages 50–74 only); and a Pap smear in the past three analysis of 2012 and 2014 5% sample of fee-for-service Medicare years (women ages 25–64 only). Authors’ analysis of 2012 and 2014 beneficiaries enrolled in stand-alone Medicare Part D plans. Behavioral Risk Factor Surveillance System (CDC, BRFSS 2012, 2014). 15. Percent of Medicare beneficiaries with dementia, hip/pelvic 9. Percent of adults with age-appropriate vaccines: Percent of adults fracture, or chronic renal failure who received a prescription age 18 and older who have received a flu shot in the past year and a drug in an ambulatory care setting that is contraindicated for pneumonia vaccine ever if age 65 and older. Authors’ analysis of 2013 that condition: Percent of fee-for-service Medicare beneficiaries and 2015 Behavioral Risk Factor Surveillance System (CDC, BRFSS age 67 and older with dementia, hip/pelvic fracture, or chronic commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 46 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) renal failure who received a prescription drug in an ambulatory of Healthcare Providers and Systems Survey data (HCAHPS n.d.), care setting that is contraindicated for that condition. Y. Zhang, as administered to adults discharged from acute-care hospitals, University of Pittsburgh, analysis of 2012 and 2014 5% sample of retrieved from retrieved from 4th quarter 2016 and 4th quarter 2014 fee-for-service Medicare beneficiaries enrolled in stand-alone CMS Hospital Compare (DHHS n.d.). Medicare Part D plans. 21. Percent of home health patients who get better at walking or 16. Percent of fee-for-service Medicare patients whose health moving around: Percent of all home health episodes in which a provider always listens, explains, shows respect, and spends person improved at walking or moving around compared to a prior enough time with them: Percent of fee-for-service Medicare patients assessment. Episodes for which the patient, at start or resumption who had a doctor’s office or clinic visit in the last 12 months and of care, was able to ambulate independently are excluded. Authors’ who reported health providers always listened carefully, explained analysis of 2013 and 2015 Outcome and Assessment Information Set things clearly, respected what they had to say, and spent enough (CMS, OASIS n.d.) as reported in CMS Home Health Compare. Data time with them. Data from 2012 and 2014 National Consumer retrieved from 3rd quarter 2016 and 2nd quarter 2014 CMS Home Assessment of Healthcare Providers and Systems (CAHPS) Health Compare (DHHS n.d.). Benchmarking Database (AHRQ , CAHPS n.d.). 22. Percent of home health patients whose wounds improved or 17. Risk-adjusted 30-day mortality among Medicare beneficiaries healed after an operation: Percent of all home health episodes in hospitalized for heart attack, heart failure, pneumonia, or stroke: which a person’s surgical wound is more fully healed compared Risk-standardized, all-cause 30-day mortality rates for fee-for- to a prior assessment. Episodes for which the patient, at start or service Medicare patients age 65 and older hospitalized with a resumption of care, did not have any surgical wounds or had only principal diagnosis of heart attack, heart failure, pneumonia, or a surgical wound that was unobservable are excluded. Authors’ stroke between July 2010 and June 2013 and July 2012 and June 2015. analysis of 2013 and 2015 Outcome and Assessment Information Set All-cause mortality is defined as death from any cause within 30 (CMS, OASIS n.d.) as reported in CMS Home Health Compare. Data days after the index admission, regardless of whether the patient retrieved from 3rd quarter 2016 and 2nd quarter 2014 CMS Home dies while still in the hospital or after discharge. Authors’ analysis Health Compare (DHHS n.d.). of Medicare enrollment and claims data retrieved from 4th quarter 23. Percent of high-risk nursing home residents with pressure 2016 and 4th quarter 2014 CMS Hospital Compare (DHHS n.d.). sores: Percent of long-stay nursing home residents impaired in 18. Central line-associated bloodstream infections (CLABSI), bed mobility or transfer, comatose, or malnourished who have Standardized Infection Ratio: All central line-associated pressure sores (stages 1–4) on target assessment. Authors’ analysis of bloodstream infections reported to the National Healthcare Safety 2013–2016 Minimum Data Set (CMS, MDS n.d.) as reported in CMS Network (NHSN) from all applicable hospital locations, including Nursing Home Compare. Data retrieved from June 1, 2016, and June intensive care units, neonatal intensive care units, and wards. 1, 2014, CMS Nursing Home Compare data files. The standardized infection ratio compares the observed number 24. Percent of long-stay nursing home residents with an of CLABSI infections in hospitals within the state reported to antipsychotic medication: Percent of long-stay nursing home NHSN to the predicted number of infections based on the referent residents that received an antipsychotic medication, excluding period, adjusting for key risk factors. Data are from the Center for residents with schizophrenia, Tourette’s syndrome, and Disease Control and Prevention’s 2013 and 2014 National and State Huntington’s disease. Authors’ analysis of 2013–2016 Minimum Healthcare-Associated Infections Progress Reports (CDC n.d.). Data Set (CMS, MDS n.d.) as reported in CMS Nursing Home 19. Percent of hospitalized patients who were given information Compare. Data retrieved from June 1, 2016, and June 1, 2014, CMS about what to do during their recovery at home: Authors’ analysis Nursing Home Compare data files. of 2013 and 2015 Hospital Consumer Assessment of Healthcare 25. Hospital admissions for pediatric asthma, per 100,000 children Providers and Systems Survey data (HCAHPS n.d.), as administered (ages 2–17): Excludes patients with cystic fibrosis or anomalies to adults discharged from acute-care hospitals, retrieved from 4th of the respiratory system, and transfers from other institutions. quarter 2016 and 4th quarter 2014 CMS Hospital Compare (DHHS Authors’ analysis of 2011 and 2013 Healthcare Cost and Utilization n.d.). Project State Inpatient Databases; not all states participate in 20. Percent of patients who reported hospital staff always managed HCUP. Estimates for total U.S. are from the Nationwide Inpatient pain well, responded when needed help to get to bathroom or Sample (AHRQ , HCUPT-SID 2011, 2013). Reported in the National pressed call button, and explained medicines and side effects: Healthcare Quality Report (AHRQ 2011, 2013). Authors’ analysis of 2013 and 2015 Hospital Consumer Assessment commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 47 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) 26. Hospital admissions among Medicare beneficiaries for patient received, were considered to be either nonemergent (care ambulatory care-sensitive conditions, per 1,000 beneficiaries was not needed within 12 hours), or emergent (care needed within ages 65–74 and 75 and older: Hospital admissions of fee-for-service 12 hours) but that could have been treated safely and effectively Medicare beneficiaries age 65–74 or age 75 and older (measure in a primary care setting. This definition excludes any emergency reported separately for each age group) for one of the following eight department visit that resulted in an admission, as well as emergency ambulatory care–sensitive (ACS) conditions: long-term diabetes department visits where the level of care provided in the ED was complications, lower extremity amputation among patients clinically indicated. J. Zheng, Harvard University, analysis of 2012 with diabetes, asthma or chronic obstructive pulmonary disease, and 2014 Medicare Enrollment and Claims Data 20% sample of hypertension, congestive heart failure, dehydration, bacterial fee-for-service Medicare beneficences age 65 and older, Chronic pneumonia, and urinary tract infection. Authors’ analysis of 2012 Conditions Warehouse (CMS, CCW 2012, 2014), using the New York and 2014 Chronic Conditions Warehouse (CCW) data, retrieved University Center for Health and Public Service Research emergency from the February 2016 CMS Geographic Variation Public Use File department algorithm developed by John Billings. (CMS, Office of Information Products and Analytics (OPIDA) 2016). 32. Total reimbursements per enrollee (ages 18–64) with employer- 27. Medicare 30-day hospital readmissions, rate per 1,000 sponsored insurance: Total per enrollee spending estimates from beneficiaries: All hospital admissions among fee-for-service a sophisticated regression model include reimbursed costs for Medicare beneficiaries age 65 and older that were readmitted health care services from all sources of payment, including the within 30 days of an acute hospital stay for any cause. A correction health plan, enrollee, and any third-party payers incurred in 2013 was made to account for likely transfers between hospitals. Authors’ and in 2014. Outpatient prescription drug charges are excluded. analysis of 2012 and 2014 Chronic Conditions Warehouse (CCW) Enrollees with capitated plans and their associated claims are also data, retrieved from the February 2016 CMS Geographic Variation excluded. Estimates for each state were adjusted for enrollees’ age Public Use File (CMS, Office of Information Products and Analytics and sex, the interaction of age and sex, partial year enrollment, and (OPIDA) 2016). regional wage difference. M. Chernew, Department of Health Care 28. Percent of short-stay nursing home residents readmitted Policy, Harvard Medical School, analysis of the Truven Marketscan within 30 days of hospital discharge to the nursing home: Percent Database. of newly admitted nursing home residents who are rehospitalized 33. Total Medicare (Parts A&B) reimbursements per beneficiary: within 30 days of being discharged from a hospital to the nursing Total fee-for-service Medicare reimbursements include payments home. V. Mor, Brown University, analysis of 2012 and 2014 Medicare for both Part A and Part B but exclude Part D (prescription drug enrollment data and Medicare Provider and Analysis Review (CMS, costs) and extra CMS payments for graduate medical education MEDPAR 2012, 2014). and for treating low-income patients. Reimbursements reflect only 29. Percent of long-stay nursing home residents hospitalized the age 65 and older fee-for-service Medicare population. Authors’ within a six-month period: Percent of long-stay residents (residing analysis of 2012 and 2014 Chronic Conditions Warehouse (CCW) in a nursing home for at least 90 consecutive days) who were data, retrieved from the February 2016 CMS Geographic Variation hospitalized within six months of baseline assessment. V. Mor, Public Use File (CMS, Office of Information Products and Analytics Brown University, analysis of 2012 and 2014 Medicare enrollment (OPIDA) 2016). data, Medicare Provider and Analysis Review File (CMS, MEDPAR 34. Mortality amenable to health care, deaths per 100,000 2012, 2014). population: Number of deaths before age 75 per 100,000 population 30. Home health patients also enrolled in Medicare with a hospital that resulted from causes considered at least partially treatable admission: Percent of home health episodes among fee-for-service or preventable with timely and appropriate medical care (see Medicare beneficiaries during which the patient was admitted to an list), as described in Nolte and McKee (Nolte and McKee, BMJ acute-care hospital. Authors’ analysis of data from CMS Medicare 2003). Authors’ analysis of mortality data from CDC restricted-use claims data as reported in CMS Home Health Compare. Data Multiple Cause-of-Death file and U.S. Census Bureau population retrieved from 4th quarter 2016 and 3rd quarter 2014 CMS Home data, 2011–2014 (NCHS, MCD n.d.). Health Compare (DHHS n.d.), representing patient experiences in Causes of death Age 2015 and 2013 respectively. Intestinal infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–14 31. Potentially avoidable emergency department visits among Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 Medicare beneficiaries, per 1,000 beneficiaries: Potentially Other infections (diphtheria, tetanus, septicaemia, poliomyelitis) . . . . . . . 0–74 avoidable emergency department visits were those that, based on Whooping cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–14 diagnoses recorded during the visit and the health care service the Measles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–14 commonwealthfund.org March 2017 AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition 48 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) Malignant neoplasm of colon and rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 39. Infant mortality, deaths per 1,000 live births: Authors’ analysis Malignant neoplasm of skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 of National Vital Statistics System–Linked Birth and Infant Death Malignant neoplasm of breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 Data, 2012 and 2013 (NCHS, NVSS), retrieved using the CDC Wide- Malignant neoplasm of cervix uteri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 ranging OnLine Data for Epidemiologic Research (WONDER) (NVSS Malignant neoplasm of cervix uteri and body of uterus . . . . . . . . . . . . . . . . . . 0–44 2012 and 2013). Malignant neoplasm of testis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 40. Percent of adults ages 18–64 who report being in fair or poor Hodgkin’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 health, or who have activity limitations because of physical, Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–44 mental, or emotional problems: Authors’ analysis of 2013 and 2015 Diseases of the thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 Behavioral Risk Factor Surveillance System (CDC, BRFSS 2013, 2015). Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–49 Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 41. Percent of adults who smoke: Percent of adults age 18 and Chronic rheumatic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 older who ever smoked 100+ cigarettes (five packs) and currently Hypertensive disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 smoke every day or some days. Authors’ analysis of 2013 and 2015 Cerebrovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 Behavioral Risk Factor Surveillance System (CDC, BRFSS 2013, All respiratory diseases (excluding pneumonia and influenza) . . . . . . . . . . 1–14 2015). Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 42. Percent of adults ages 18–64 who are obese (Body Mass Index Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 [BMI] ≥ 30): Authors’ analysis of 2013 and 2015 Behavioral Risk Peptic ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 Factor Surveillance System (CDC, BRFSS 2013, 2015). Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 43. Children ages 10–17 who are overweight or obese (BMI ≥ Abdominal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 85th percentile): Overweight is defined as an age- and gender- Cholelithiasis and cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 specific body mass index (BMI-for-age) between the 85th and Nephritis and nephrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 94th percentile of the CDC growth charts. Obese is defined as a Benign prostatic hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 BMI-for-age at or above the 95th percentile. BMI was calculated Maternal death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All based on parent-reported height and weight. For more information, Congenital cardiovascular anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0–74 see www.nschdata.org. Data from the National Survey of Perinatal deaths, all causes, excluding stillbirths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All Children’s Health, assembled by the Child and Adolescent Health Misadventures to patients during surgical and medical care . . . . . . . . . . . . . . . All Measurement Initiative (CAHMI, NCHS 2011/2012). Ischaemic heart disease: 50% of mortality rates included . . . . . . . . . . . . . . . . . 0–74 44. Percent of adults ages 18–64 who have lost 6 or more teeth 35. Years of potential life lost before age 75: Robert Wood Johnson because of tooth decay, infection, or gum disease: Authors’ analysis Foundation analysis of National Vital Statistics System Mortality of 2012 and 2014 Behavioral Risk Factor Surveillance System (CDC, Data, 2012 and 2014, using the Centers for Disease Control and BRFSS 2012, 2014). Prevention (CDC) National Center for Injury Prevention and Control Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved October 2016 from Robert Wood Johnson Foundation National DataHub (NVSS 2012 and 2014). 36. Breast cancer deaths per 100,000 female population: Authors’ analysis of NVSS–Mortality Data, 2012 and 2014 (NCHS, NVSS n.d.), retrieved using the CDC Wide-ranging OnLine Data for Epidemiologic Research (WONDER) (NVSS 2012 and 2014). 37. Colorectal cancer deaths per 100,000 population: Authors’ analysis of NVSS–Mortality Data, 2012 and 2014 (NCHS, NVSS n.d.), retrieved using the CDC Wide-ranging OnLine Data for Epidemiologic Research (WONDER) (NVSS 2012 and 2014). 38. Suicide deaths per 100,000 population: Authors’ analysis of NVSS–Mortality Data, 2012 and 2014 (NCHS, NVSS n.d.), retrieved using the CDC Wide-ranging OnLine Data for Epidemiologic Research (WONDER) (NVSS 2012 and 2014). commonwealthfund.org March 2017