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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THE COMMONWEALTH
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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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THE COMMONWEALTH
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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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THE COMMONWEALTH
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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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THE COMMONWEALTH
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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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THE COMMONWEALTH
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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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THE COMMONWEALTH
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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
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