THE COMMONWEALTH

FUND

AAiming Higheriming HigherA State Scorecard on Health System PerformanceA State Scorecard on Health System Performance

Cathy SchoenSenior Vice President

The Commonwealth Fund

Alliance for Health ReformJune 15, 2007

On behalf of Rutgers University Center for State Health Policy and Commonwealth Fund Co-Authors

www.commonwealthfund.org

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THE COMMONWEALTH

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Purpose and MethodsPurpose and Methods• Aims to stimulate discussion, collaboration, and policy action• Modeled on National Scorecard

– 5 dimensions: access, quality, avoidable hospital use and costs, equity, and healthy lives

– Contrasts to highest performers• Ranks states on indicators and dimensions

– 32 indicators– Dimension rank = average of indicator ranks– Overall rank = average of dimension ranks

• Equity– Gaps for vulnerable group (income, insurance, race/ethnicity)

on subset of 11 indicators

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Aiming Higher: Key FindingsAiming Higher: Key Findings• Wide variation among states, huge potential to improve

– Two to three-fold differences in many indicators– Leaders offer benchmarks

• Leading states consistently out-perform lagging states – Suggests policies and systems linked to better performance– Distinct regional patterns, but also exceptions

• Access and quality highly correlated across states• Significant opportunities to address cost, quality, access

– Quality not associated with higher cost across states• All states have room to improve

– Even best states perform poorly on some indicators

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Gains to Nation if All States Achieved Top State Gains to Nation if All States Achieved Top State PerformancePerformance

• More People Covered– 22 million additional adults and children insured

• More Getting the Right Care– Nearly 9 million additional adults (50+) and 4 million diabetics

would receive recommended care– 750,000 children immunized

• More Getting Primary Care– 22 million adults and 10 million children with primary care

• Less Avoidable Hospital Utilization – More than 1 million fewer Medicare hospital admissions and

readmissions per year (Savings of $5 billion+ per year)• Costs

– $22 billion annual Medicare savings if high cost states came down to average

• Healthy Lives– 90,000 fewer premature deaths

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QUALITYQUALITY

• Getting the Right Care• Coordinated Care• Patient-Centered Care

5065

94

75

4959

8873

40 42

82

59

33 32

71

4833 29

67

46

0

50

100

Adults age 50+rec eived

recommendedpreventive c are

Adult diabetic srec eived threerec ommended

diabetes servic es

Children ages19–35 monthsreceived five

vac c ines

Children w ithdental and medic al

preventive c arevis its

Best S tate T op 5 S tates Avg All S tates Median Bottom 5 S tates Avg Wors t S tate

PercentState Variation: Ambulatory Care Quality Indicators

DATA: Adult preventive care – 2002/2004 BRFSS; Adult diabetic preventive care – 2002/2004 BRFSS; Child vaccines – 2005 National Immunization Survey; Child medical and dental visits – 2003 National Survey of Children’s HealthSOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007

QUALITY: THE RIGHT CARE

Percent of patients who received recommended care

State Variation: Hospital Care Quality Indicators, 2004

8897 91

828897

908183

9384

747989

7567

7988

66 64

0

50

100

All three c onditions(10 indicators )

Ac ute myoc ardialinfarc tion

Congestive heartfailure

Pneumonia

Best S tate T op 5 S tates Avg All S tates Median Bottom 5 S tates Avg Worst S tate

(5 indicators) (2 indicators)(3 indicators)

DATA: 2004 CMS Hospital CompareSOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007

QUALITY: THE RIGHT CARE

State Variation: Surgical Infection Prevention, 2005

9083

7057

50

0

50

100

Best State Top 5 StatesAvg

All S tatesMedian

Bottom 5States Avg

Wors t State

QUALITY: THE RIGHT CARE

Percent of adult surgical patients who received appropriate timing of antibiotics to prevent infections*

* Comprised of two indicators: before and after surgery.DATA: 2005 CMS Hospital CompareSOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007

89

61 67

88

60 64

81

48 49

71

3626

66

3421

0

50

100

Adults w ith a usual sourc eof c are

Children w ith a medic alhome

H eart failure patientsgiven disc harge

instruc tions

Bes t S tate T op 5 S tates Avg All S tates Median Bottom 5 S tates Avg Wors t S tate

Percent

DATA: Adult usual source of care – 2002/2004 BRFSS; Child medical home – 2003 National Survey of Children’s Health; Heart failure discharge instructions – 2004-2005 CMS Hospital CompareSOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007

State Variation: Coordination of Care IndicatorsQUALITY: COORDINATED CARE

PercentState Variation: Hospital Admissions Indicators

138 7

1814

9 8

2018 1612

2722 23

17

39

24 2518

46

0

25

50

Medic arebenefic iaries

readmitted to hospitalw ithin 30 days

Nurs ing homeres idents admitted to

hospita l

Nurs ing homeres idents readmittedto hospital w ithin 3

months

Home health patientsadmitted to hospital

Best S tate T op 5 S tates Avg All S tates Median Bottom 5 S tates Avg Wors t S tate

DATA: Medicare readmissions – 2003 Medicare SAF 5% Inpatient Data; Nursing home admission and readmissions – 2000 Medicare enrollment records and MedPAR file; Home health admissions – 2004 Outcome and Assessment Information SetSOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007

AVOIDABLE HOSPITAL USE AND COSTS

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EQUITYEQUITY

• Based on gaps between most vulnerable to national average– Low-income (below 100% or 200% of

poverty)– Uninsured– Racial, ethnic minority

54 4856

7161

76

0

50

100

NationalA verage

T op 5S tates

Average

Bottom 5States

Average

>200% of poverty 200% of poverty or less

Percent of adults age 50+ who did not receive recommended preventive care

Lack of Recommended Preventive Care by Income and Insurance

SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007

Note: Top 5 states refer to states with smallest gap between national average and low income/uninsured. Bottom 5 states refer to states with largest gap between national average and low income/uninsured.DATA: 2002/2004 BRFSS

59 54 60

7865

87

NationalAverage

T op 5 S tatesAverage

Bottom 5States

Average

Insured U ninsured

By income By insurance

EQUITY

94 84 89110

194

123

184

232

0

50

100

150

200

250

300

N ational Average Top 5 StatesAverage

All States Median Bottom 5 StatesAverage

White Blac k

Deaths* per 100,000 Population

Mortality Amenable to Health Care by Race, National Average and State Variation

HEALTHY LIVES

*Age-standardized deaths before age 75 from select causes; includes ischemic heart diseaseNote: Top 5 states refer to states with smallest gap between national average and black. Bottom 5 states refer to states with largest gap between national average and black.DATA: Analysis of 2002 CDC Multiple Cause-of-Death data files using Nolte and McKee methodology, BMJ 2003.SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007

Overall U.S. Average = 103 deaths per 100,000

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Aiming HigherAiming HigherUrgent need for action that takes a whole-system population perspective and addresses access, quality and efficiency

• Universal coverage with meaningful access: foundation for quality and efficient care

• Wide variations point to opportunities to learn• Information systems and better information are

critical for improvement• National leadership and public and private

collaborative improvement initiatives

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Acknowledgments:Acknowledgments:Rutgers University Center for State Health Policy Rutgers University Center for State Health Policy

and The Commonwealth Fund Co-Authorsand The Commonwealth Fund Co-Authors

Joel C. Cantor, ScDDirector, Rutgers University Center for State Health Policy

Dina Belloff, MASenior Research Analyst, Rutgers University Center for State Health Policy

Sabrina How, MPAResearch Associate, The Commonwealth Fund

Douglas McCarthy, MBASenior Research Advisor, The Commonwealth Fund

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Related Commission ReportsRelated Commission Reports• Why Not the Best? Results from a National Scorecard on U.S.

Health System Performance (Sept. 2006). The Commonwealth Fund Commission on a High Performance Health System.

• “U.S. Health System Performance: A National Scorecard” (Sept. 20, 2006). C. Schoen, K. Davis, S. K. H. How, and S. C. Schoenbaum. Health Affairs Web Exclusive.

• The Agency for Healthcare Research and Quality's 2006 National Healthcare Quality Report (March 2007). S. C. Schoenbaum, D. McCarthy, and C. Schoen.

• Public Views on Shaping the Future of the U.S. Health System (August 2006). C. Schoen, S. K. H. How, I. Weinbaum, J. E. Craig, Jr., and K. Davis.

• Framework for a High Performance Health System for the United States (August 2006). The Commonwealth Fund Commission on a High Performance Health System.

For these and other Commonwealth Fund Reports visit the Fund website:

www.commonwealthfund.org