THE COMMONWEALTH

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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

50

65

94

75

4959

88

73

40 42

82

59

33 32

71

48

33 29

67

46

0

50

100

Adults age 50+

rec eived

rec ommended

preventive c are

Adult diabetic s

rec eived three

rec ommended

diabetes servic es

Children ages

19–35 months

rec eived five

vac c ines

Children w ith

dental and medic al

preventive c are

vis its

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

Percent

State 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 Health

SOURCE: 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

9182

8897

908183

9384

7479

89

7567

7988

66 64

0

50

100

All three c onditions

(10 indic ators )

Ac ute myoc ardial

infarc tion

Congestive heart

failure

Pneumonia

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

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

DATA: 2004 CMS Hospital Compare

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

QUALITY: THE RIGHT CARE

State Variation: Surgical Infection Prevention, 2005

9083

70

5750

0

50

100

Best State Top 5 States

Avg

All States

Median

Bottom 5

States 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 Compare

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

89

6167

88

60 64

81

48 49

71

3626

66

34

21

0

50

100

Adults w ith a usual sourc e

of c are

Children w ith a medic al

home

H eart failure patients

given disc harge

ins truc tions

Best 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 Compare

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

State Variation: Coordination of Care Indicators

QUALITY: COORDINATED CARE

Percent

State Variation: Hospital Admissions Indicators

138 7

1814

9 8

2018 16

12

2722 23

17

39

24 25

18

46

0

25

50

Medic are

benefic iaries

readmitted to hospita l

w ithin 30 days

Nurs ing home

res idents admitted to

hospita l

Nurs ing home

res idents readmitted

to hospita l w ithin 3

months

Home health patients

admitted to hospita l

Bes t 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 Set

SOURCE: 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

5448

56

7161

76

0

50

100

National

Average

T op 5

S tates

Average

Bottom 5

S tates

Average

>200% of poverty 200% of poverty or les s

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

5954

60

78

65

87

National

A verage

T op 5 S tates

A verage

Bottom 5

S tates

A verage

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 States

Average

All States Median Bottom 5 States

Average

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 disease

Note: 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 Higher

Urgent 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, ScD

Director, Rutgers University Center for State Health Policy

Dina Belloff, MA

Senior Research Analyst, Rutgers University Center for State Health Policy

Sabrina How, MPA

Research Associate, The Commonwealth Fund

Douglas McCarthy, MBA

Senior 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