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THE COMMONWEALTH
FUND
National Scorecard onU.S. Health System Performance:
Complete Chartpack
Cathy Schoen, Senior Vice PresidentSabrina K. H. How, Research Associate
September 2006
This Chartpack presents data for all indicators scored in the National Scorecard on U.S. Health System Performance. Charts display average performance for the U.S. as a whole and the range of performance found within the U.S or compared to other countries.
The charts accompany the Health Affairs article, “U.S. Health System Performance, A National Scorecard,” and the Technical Report published by The Commonwealth Fund, which together provide detailed information on scoring and results:
– C. Schoen, K. Davis, S. K. H. How, and S. C. Schoenbaum,“U.S. Health System Performance: A National Scorecard,”Health Affairs Web Exclusive (Sept. 20, 2006):w457–w475.
– C. Schoen and S. K. H. How, National Scorecard on U.S.Health System Performance: Technical Report (New York:The Commonwealth Fund, Sept. 2006).
In addition to the Chartpack, the Technical Appendix includes full descriptions of performance indicators and data sources.
See the last page for a list of Scorecard-related publications that are available for download.
NATIONAL SCORECARD: COMPLETE CHARTPACK
Scores: Dimensions of a High Performance Health System
69
71
67
51
71
66
0 100
Long, Healthy &Productive Lives
Quality
Access
Efficiency
Equity
OVERALL SCORE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 4
SECTION 1. LONG, HEALTHY, AND PRODUCTIVE LIVES
Scored Indicators:
1. Mortality amenable to health care
2. Infant mortality rate
3. Healthy life expectancy at age 60
4. Adults under 65 limited in any activities because of health problems
5. Children who missed 11 or more days of school due to illness or injury
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
LONG, HEALTHY & PRODUCTIVE LIVES
5
Mortality Amenable to Health Care
97 97 99106 107109109
115115
129130132
7584 88 88 88
8192
0
50
100
150
Deaths per 100,000 population*
110
8490
103
119
134
U.S.avg
10th 25th Med-ian
75th 90th
Percentiles
Internationalvariation, 1998
State variation,2002
* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.See Technical Appendix for list of conditions considered amenable to health care in the analysis.Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003);State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology.
Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
LONG, HEALTHY & PRODUCTIVE LIVES
6
7.0
5.3
6.0
7.1
8.1
9.1
U.S.avg
10th 25th Med-ian
75th 90th
Infant Mortality Rate, 2002
* 2001.Data: International estimates—OECD Health Data 2005;State estimates—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2005a).
2.2
3.0 3.03.3 3.5
4.1 4.1 4.1 4.2 4.2 4.4 4.4 4.5 4.55.0 5.0 5.0 5.0 5.1 5.2 5.4 5.6
7.0
0
5
10
Infant deaths per 1,000 live births
Percentiles
International variation State variation
LONG, HEALTHY & PRODUCTIVE LIVES
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 7
Healthy Life Expectancy at Age 60, 2002
2220 20 20 20 20 19 19 19 19 19 19 19 19 18 18 18 18 18 18 18 17 1718 17 17 16 17 17 16 16 16 16 16 16
1816 16 16 16 16 15 15 15 15
14
0
10
20
30 Women Men
Years
Data: The World Health Report 2003 (WHO 2003, Annex Table 4).
Developed by the World Health Organization, healthy life expectancy is based on life expectancy adjusted for time spent in poor health due to disease and/or injury
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
LONG, HEALTHY & PRODUCTIVE LIVES
8
Working-Age Adults with Health Limits on Activities or Work, by Age, Race/Ethnicity, Household Income, and Insurance Status, 2004
14.9
8.3
13.4
24.2
11.5
5.0
10.2
19.420.1
11.9
19.0
31.5
0
20
40
Total Age 18–29 Age 30–49 Age 50–64
U.S. average Top 10% states Bottom 10% states
14.7
15.0
10.7
14.0
23.3
27.4
5.4
9.8
15.1
15.9
0 30
Uninsured
Insured
$50,000+
$25,000-$49,999
<$25,000
AI/AN
Asian
Hispanic
Black
White
Percent of adults (ages 18–64) limited in any activities because of physical, mental, or emotional problems
Note: Data were not available for Hawaii in 2004. AI/AN = American Indian or Alaskan Native.Data: B. Mahato, Columbia University analysis of 2004 Behavioral Risk Factor Surveillance System.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
LONG, HEALTHY & PRODUCTIVE LIVES
9
Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).
Percent of children (ages 6–17) who missed 11 or more school days due to illness or injury during past year
School Absences Due to Illness or Injury, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
4.7
4.2
3.6
4.8
5.5
8.1
3.8
5.2
8.0
4.2
0 5 10
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
LONG, HEALTHY & PRODUCTIVE LIVES
10
SECTION 2. QUALITY
Quality includes indicators organized into four groups:
– The right care
– Coordinated care
– Safe care
– Patient-centered, timely care
The Scorecard scores each group of indicators separately, and then averages the four scores to create the overall score for Quality.
QUALITY
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 11
The Right Care
Scored Indicators:
1. Adults received recommended screening and preventive care
2. Children received recommended immunizations and preventive care• Received all recommended doses of five key vaccines• Received both medical and dental preventive care visits
3. Needed mental health care and received treatment• Adults• Children
4. Chronic disease under control• Adults with diabetes whose HbA1c level <9%• Adults with hypertension whose blood pressure <140/90 mmHg
5. Hospitalized patients receive recommended care for AMI, CHF,and pneumonia
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
12
Receipt of Recommended Screening and Preventive Care for Adults,by Family Income and Insurance Status, 2002
31
46
52
39
48
56
49
0 50 100
Uninsured all year
Uninsured part year
Insured all year
<200% of poverty
200%–399% of poverty
400%+ of poverty
National
Percent of adults (ages 18+) who received all recommended screening andpreventive care within a specific time frame given their age and sex*
* Recommended care includes seven key screening and preventive services: blood pressure,cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
13
89
81 7977
69
77
0
50
100
White Black Hispanic
400%+ of poverty <100% of poverty
Immunizations for Young Children, by Top and Bottom States, Race/Ethnicity, and Family Income, 2003
75
87
79
83
89
79
77
77
73
71
0 50 100
<100% of poverty
400%+ of poverty
AI/AN
Asian/PI
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
* Recommended vaccines include: 4 doses of diphtheria-tetanus-pertussis (DTP), 3+ doses of polio, 1+ dose of measles-mumps-rubella, 3+doses of Haemophilus influenzae type B, and 3+ doses of hepatitis B vaccine.PI = Pacific Islander; AI/AN = American Indian or Alaskan Native. Data: National Immunization Survey (AHRQ 2005a, 2005b).
Percent of children (ages 19–35 months) who received all recommended doses of five key vaccines*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
14
Percent of children (ages <18) received BOTH a medical and dental preventive care visit in past year
Preventive Care Visits for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
35
63
70
58
62
48
73
59
48
49
0 50 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
15
Adults with Serious Mental Illness Who Received Treatment,by Race/Ethnicity, Family Income, and Residence Location, 2003
47
50
37
47
29
54
42
17
53
0 50 100
Urban
Rural
<100% of poverty
400%+ of poverty
Asian
Hispanic
Black
White
U.S. average
* Serious mental illness is defined as having a diagnosable mental, behavioral, or emotional disorder which resulted in functional impairment that significantly impeded one or more major life activities. Mental health treatment/counseling includes any hospital or outpatient care or medications. Data: National Survey on Drug Use and Health (AHRQ 2005a, 2005b).
Percent of adults (ages 18+) with serious mental illness who received mental health treatment or counseling in the past year*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
16
* Children with current emotional, developmental, or behavioral health condition requiring treatment or counseling who received needed care during the year.Data: 2003 National Survey of Children’s Health (HRSA 2005; Retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).
Percent of children (ages <18) who needed and received mental health care in past year*
Mental Health Care for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
34
63
64
52
65
47
74
59
53
42
0 50 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
17
Diabetic Adults Who Have Blood Glucose Levels Under Fair Control, National and Managed Care Plan Type
Note: National estimate includes ages 18+ and plan estimates include ages 18–75.Data: National estimate—National Health and Nutrition Examination Survey (AHRQ 2005a); Plan estimates—Health Plan Employer Data and Information Set (NCQA 2005a, 2005b).
79
89
6974
69
77
50
5864
23
0
50
100
National P rivate Medic are Medic aid
90th %ile Mean 10th %ile
Percent of adults with diagnosed diabetes whose HbA1c level <9.0%
5863
66 68 6967
73 76 77 78
4552 52 51 51
0
50
100
2000 2001 2002 2003 2004
Private Medicare Medicaid
Annual averagesManaged care plans (2004)(1999–2002)
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
18
Adults with Hypertension Who Have Blood Pressure Under Control, National and Managed Care Plan Type
Percent of adults with hypertension whose blood pressure <140/90 mmHg
75 7471
29
67 6562
56 5548
0
50
100
National Private Medicare Medicaid
90th %ile Mean 10th %ile
5255
5862
67
47
5457
6165
46
53 5359
61
0
50
100
2000 2001 2002 2003 2004
Private Medicare Medicaid
Note: National estimate includes ages 18+ and plan estimates include ages 46–85.Data: National estimate—National Health and Nutrition Examination Survey (AHRQ 2005a); Plan estimates—Health Plan Employer Data and Information Set (NCQA 2005a, 2005b).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
19
Annual averagesManaged care plans (2004)(1999–2002)
84
9991
75
88 8780
0
50
100
Median Best 90th %ile 10th %ile Best 90th %ile 10th %ile
States
Percent of patients who received recommended care for all three conditions
Hospitals
Composite: Hospital Quality of Care for Heart Attack, Heart Failure, and Pneumonia, by Hospitals and States, 2004
* See following chart for description of ten clinical indicators.Data: A. Jha and A. Epstein, Harvard University analysis of data from Hospital Quality Alliance national reporting system and CMS Hospital Compare.
This is a composite of ten clinical indicators of the quality of care for acutemyocardial infarction (heart attack), congestive heart failure, and pneumonia*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
20
Hospital Quality of Care for Heart Attack, Heart Failure,and Pneumonia, by Hospitals and States, 2004
HOSPITALS STATES
Percent of patients who received recommended care: Median Best
90th percentile
10th percentile Best
90th percentile
10th percentile
Acute myocardialinfarction (AMI)(5 indicators)
92 100 98 80 97 96 89
Congestive heartfailure (CHF)(2 indicators)
83 100 94 62 91 89 79
Pneumonia(3 indicators)
78 99 88 66 82 79 69
COMPOSITE OF10 INDICATORS
84 99 91 75 88 87 80
AMI—aspirin within 24 hours before or after arrival at the hospital and at discharge, beta-blocker within 24 hours after arrival and at discharge, and angiotensin-converting enzyme (ACE) inhibitor for left ventricular systolic dysfunction; CHF—assessment of left ventricular function and ACE inhibitor for left ventricular dysfunction; Pneumonia—timing of initial antibiotic therapy, pneumococcal vaccination, and assessment of oxygenation.Data: A. Jha and A. Epstein, Harvard University analysis of data from Hospital Quality Alliance national reporting systemand CMS Hospital Compare.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
21
Coordinated Care
Scored Indicators:
1. Adults under 65 with an accessible primary care provider
2. Children with a medical home
3. Care coordination at hospital discharge• Hospitalized patients with new Rx: Medications were reviewed
at discharge• Heart failure patients received written instructions at discharge• Follow-up within 30 days after hospitalization for mental health
disorder
4. Nursing homes: hospital admissions and readmissions among residents
5. Home health: hospital admissions
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
22
Having an Accessible Primary Care Provider, by Age Group,Family Income, and Insurance Status, 2002
69
82 8480
66
74
53
74
54
38
0
50
100
Total 65+ years 400%+ ofpoverty
<200% ofpoverty
19–64years
400%+ ofpoverty
<200% ofpoverty
Insured all year
Uninsuredpart year
Uninsuredall year
Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.
Percent of adults with a usual source of care who provides preventive care, care for new and ongoing health problems, and referrals, and who is easy to get to
Elderly adults Nonelderly adults
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
23
* Child had 1+ preventive visit in past year; access to specialty care; personal doctor/nurse who usually/always spent enough time and communicated clearly, provided telephone advice or urgent care and followed up after the child’s specialty care visits.Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).
23
53
58
39
53
36
60
46
30
31
0 50 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
Children with a Medical Home, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
Percent of children who have a personal doctor or nurse and receive care that is accessible, comprehensive, culturally sensitive, and coordinated*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
24
86
7773 72
69 67
0
50
100
GER AUS UK CAN NZ US
Percent of hospitalized patients with new prescription who reported prior medications were reviewed at discharge
Medications Reviewed When Discharged from the Hospital,Among Sicker Adults in Six Countries, 2005
GER=Germany; AUS=Australia; UK=United Kingdom; CAN=Canada; NZ=New Zealand; US=United States.Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
25
Heart Failure Patients Given Written Instructions or Educational Materials When Discharged, by Hospitals and States, 2004
50
87
9
6460
49
3326
0
50
100
NationalAverage
90th %ile 10th %ile Top 10% Top 25% Median Bottom 25% Bottom 10%
Percent of heart failure patients discharged home with written instructions or educational material*
* Discharge instructions must address all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.Data: National and hospital estimates—A. Jha and A. Epstein, Harvard University analysis of data from Hospital Quality Alliance national reporting system; State estimates—Retrieved from Hospital Compare database at http://www.hospitalcompare.hhs.gov.
Hospitals States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
26
Managed Care Health Plans: 30-Day Follow-UpAfter Hospitalization for Mental Illness, 2000–2004
8680 81
76
6154
65
39
22
0
50
100
Private Medicare Medicaid
90th %ile Mean 10th %ile
Percent of health plan members (ages >6) who received inpatient treatment for a mental health disorder and had follow-up within 30 days after hospital discharge
71 73 74 74 76
59 61 61 60 61
55 5256 56 55
0
50
100
2000 2001 2002 2003 2004
Private Medicare Medicaid
Annual averagesManaged care plans (2004)
Data: Health Plan Employer Data and Information Set (NCQA 2005a, 2005b).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
27
Nursing Homes: Hospital Admission and Readmission RatesAmong Nursing Home Residents, per State, 2000
16
89
12
19
21
0
10
20
30
Median Beststate
10th%ile
25th%ile
75th%ile
90th%ile
Percent
12
78
10
13
16
0
10
20
30
Median Beststate
10th%ile
25th%ile
75th%ile
90th%ile
Hospitalization rates Re-hospitalization rate (within 3 months of
nursing home admission)
Data: V. Mor, Brown University analysis of Medicare enrollment data and Part A claims data for all Medicare beneficiaries who entered a nursing home and had a Minimum Data Set assessment during 2000.
Percent
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
28
Home Health Care: Hospital Admissions,by Agencies and States, 2003–2004
28
17
29
47
23
38
0
30
60
Nationalaverage
Top 25% Median Bottom 25% Top 10% Bottom 10%
Percent of home health episodes that ended with an acute care hospitalization
Data: Outcome and Assessment Information Set (Pace et al. 2005).
Agencies States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
29
Safe Care
Scored Indicators:
1. Patients reported medical, medication, or lab test error
2. Unsafe drug use• Ambulatory care visits for treating adverse drug effects• Children prescribed antibiotics for throat infection without
a “strep” test• Elderly used 1 of 33 inappropriate drugs
3. Nursing home residents with pressure sores
4. Hospital-standardized mortality ratios
Other Indicators:
1. Nosocomial infections in intensive care unit patients
2. AHRQ indicators for patient safety in hospitals: trends
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
30
Medical, Medication, and Lab Errors Among Sicker Adults, 2005
22 2325
2730
34
0
30
60
UK GER NZ AUS CAN US
33
49
24
3436 35
31
White Black Hispanic Aboveaverageincome
Belowaverageincome
Insured Uninsured
International comparison United States, by race/ethnicity,income, and insurance status
Percent reporting medical mistake, medication error, or lab error in past two years
UK=United Kingdom; GER=Germany; NZ=New Zealand; AUS=Australia; CAN=Canada; US=United States.Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
31
Ambulatory Care Visits for Treating Adverse Drug Effects, 1995–2001
Data: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (Zhan et al. 2005).
Visits per 1,000 population per year
15
10
21
1615
8
14
16
19
11
0
10
20
30
Total
Mal
e
Femal
e
White
Black
Other
Northea
st
Mid
west
SouthW
est
11
15
131112
1011
1995 1996 1997 1998 1999 2000 2001
By gender, race, and region, 2001 Annual averages
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
32
Potentially Inappropriate Antibiotic Prescribingfor Children with Sore Throat
Percent of children (ages 3–17) who received antibiotic at visit for sore throat
Note: National estimate includes ages 3–17 and plan estimates include ages 2–18.* A strep test means a rapid antigen test or throat culture for group A streptococcus.Data: National estimate—National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey(Linder 2005); Plan estimates—Health Plan Employer Data and Information Set (NCQA 2005a, 2005b).
12
23
43
27
4645
75
0
40
80
National Private Medicaid
10th %ile Mean 90th %ile
Percent of children prescribed antibiotics for throat infection without receiving a “strep” test*
66
59 59
47 46
53 52
44
54
0
40
80
1995 1996 1997 1998 1999 2000 2001 2002 2003
Probability of bacterialinfection (15%–36%)
(1997–2003)Managed care plans
(2004)
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
33
Inappropriate Use of Medications by Elderly, 1996–2002
Percent of community-dwelling elderly adults (ages 65+) who reported taking at least 1 or more of 33 drugs that are potentially inappropriate for the elderly
18
14
22
19 18
12
17
20 20
15
0
10
20
30
21
18
14
20
1996 1998 2000 2002
By gender, race, and region, 2002
Data: Medical Expenditure Panel Survey (AHRQ 2005a).
Annual averages
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
34
13
89
1618
19
1415
2223
0
15
30
High-risk residents
Pressure Sores Among High-Risk and Short-Stay Residentsin Nursing Facilities
Percent of nursing home residents with pressure sores
AI/AN = American Indian or Alaskan Native.Data: Nursing Home Minimum Data Set (AHRQ 2005a, 2005b).
Short-stay residents
High-risk residents
Short-stay residents
White 13% 21%
Black 17 26
Hispanic 15 25
Asian 12 22
AI/AN 17 23
State distribution, 2004 By race/ethnicity, 2003
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
35
Hospital-Standardized Mortality Ratios, 2000–2002
8593 94 97 100 103 106 106
112118
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10
Ratio of actual to expected deaths in each decile (x 100)
Decile of hospitals ranked by actual to expected deaths ratios
See Technical Appendix for methodology.Data: B. Jarman analysis of Medicare discharges from 2000 to 2002 for conditions leading to 80 percent of all hospital deaths.
Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors. Medicare national average for 2000 = 100
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
36
Nosocomial Infections in Intensive Care Unit Patients, 2002–2004
Central line-associated bloodstream infection rate, per 1,000 days use Percentile
Type of ICU No. of units 10% 25% 50% 75% 90%
Medical 94 0.5 2.4 3.9 6.4 8.8
Medical-surgical—major teaching 100 1.7 2.6 3.4 5.1 7.6
Medical-surgical—all others 109 0.8 1.6 3.1 4.3 6.1
Surgical 99 0.0 2.0 3.4 5.9 8.7
High-risk nursery(infants weighing 1,000 grams or less) 104 1.6 5.4 8.5 11.6 16.1
Ventilator-associated pneumonia rate, per 1,000 days use Percentile
Type of ICU No. of units 10% 25% 50% 75% 90%
Medical 92 0.5 2.1 3.7 6.2 8.9
Medical-surgical—major teaching 99 1.2 2.6 4.6 7.2 9.9
Medical-surgical—all others 109 1.7 2.9 5.1 6.7 8.9
Surgical 98 2.2 4.7 8.3 12.2 17.9
High-risk nursery(infants weighing 1,000 grams or less) 102 0.0 0.0 2.4 5.8 8.5
Data: ~300 hospitals participating in the National Nosocomial Infections Surveillance (NNIS) System (NNIS 2004, Tables 1,3).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
37
Potentially Preventable Adverse Events and Complicationsof Care in Hospitals, National and Medicare Trends
Risk-adjusted rate per 10,000 discharges* 1997/1998** 2000 2002 2003
Decubitus ulcer (pressure sore)National 199 217 233 NAMedicare 206 225 251 267
Postoperative pulmonary embolismor deep vein thrombosis
National 65 75 84 NAMedicare 62 71 86 92
Postoperative sepsisNational 85 105 116 NAMedicare 80 97 111 120
Postoperative respiratory failureNational 23 34 40 NAMedicare 25 34 46 50
Accidental puncture or lacerationNational 27 33 38 NAMedicare 31 32 36 34
Infection due to medical careNational 18 20 23 NAMedicare 20 20 24 25
* Rates exclude complications present on admission and are adjusted for gender, comorbidities,and diagnosis-related group clusters. ** National rate is for 1997, Medicare rate is for 1998.Data: National estimates—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at http://www.ahrq.gov/HCUPnet); Medicare estimates—MedPAC analysis of Medicare administrative data using AHRQ indicators and methods (MedPAC 2005, Chart 3-3).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: SAFE CARE
38
Patient-Centered, Timely Care
Scored Indicators:
1. Ability to see doctor on same/next day when sick or needed medical attention
2. Very/somewhat easy to get care after hours without going to the emergency room
3. Doctor–patient communication: always listened, explained, showed respect, spent enough time
4. Adults with chronic conditions given self-management plan
5. Patient-centered hospital care
Other Indicator:
1. Physical restraints in nursing homes
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: PATIENT-CENTERED, TIMELY CARE
39
58 5649 45
3023
2313
1716
17
13
0
50
100
NZ GER AUS UK US CAN
Next day
Same day
Percent of adults
3
13 1015
23
36
NZ GER AUS UK US CAN
6 days or more
Waiting Time to See Doctor When Sick or Need Medical Attention, Sicker Adults in Six Countries, 2005
NZ=New Zealand; GER=Germany; AUS=Australia; UK=United Kingdom; US=United States; CAN=Canada.Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).
Last time you were sick or needed medical attention,how quickly could you get an appointment to see a doctor?
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: PATIENT-CENTERED, TIMELY CARE
40
Difficulty Getting Care on Nights, Weekends, Holidays WithoutGoing to the ER, Among Sicker Adults in Six Countries, 2005
2528
38
5459 61
0
50
100
GER NZ UK CAN AUS US
Percent of adults who sought care reporting “very” or “somewhat” difficult
GER=Germany; NZ=New Zealand; UK=United Kingdom; CAN=Canada; AUS=Australia; US=United States.Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: PATIENT-CENTERED, TIMELY CARE
41
55
63
555460
69
6165
7467
0
50
100
National (2002) Private Medicare Medicaid
10th %tile Mean 90th %tile
Doctor–Patient Communication: Doctor Listened Carefully,Explained Things, Showed Respect, and Spent Enough Time,
National and Managed Care Plan Type
Percent of adults (ages 18+) reporting “always”
Data: National rate—2002 Medical Expenditure Panel Survey (AHRQ 2005a);Plan rates—National CAHPS Benchmarking Database (data provided by NCQA).
Managed care plans (2004)
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: PATIENT-CENTERED, TIMELY CARE
42
* Adult reported at least one of six conditions: hypertension, heart disease, diabetes, arthritis, lung problems (asthma, emphysema, etc.), or depression.CAN=Canada; US=United States; NZ=New Zealand; AUS=Australia; UK=United Kingdom; GER=Germany.Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).
6558 56
5045
37
0
50
100
CAN US NZ AUS UK GER
Percent of adults with chronic conditions* whose doctor gave plan to manage care at home
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: PATIENT-CENTERED, TIMELY CARE
43
Adults with Chronic Conditions:Receipt of Self-Management Plan in Six Countries, 2005
7063 60
93 91100
7974 70
6152 49
0
50
100
Staff managed pain well Staff responded when needed help Staff explained medicines and side effects
Average Best hospital 90th %ile hospitals 10th %ile hospitals
Patient-Centered Hospital Care: Staff Managed Pain, RespondedWhen Needed Help, and Explained Medicines, by Hospitals, 2005
Percent of patients reporting “always”
* Patient’s pain was well controlled and hospital staff did everything to help with pain.** Patient got help as soon as wanted after patient pressed call button and in getting to the bathroom/using bedpan.*** Hospital staff told patient what medicine was for and described possible side effects in a way that patient could understand.Data: CAHPS Hospital Survey results for 254 hospitals submitting data in 2005. National CAHPS Benchmarking Database.
* *****
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: PATIENT-CENTERED, TIMELY CARE
44
Physical Restraints in Nursing Facilities
7
23
12
14
0
10
20
Nationalaverage
Top 10% Top 25% Bottom25%
Bottom10%
87
11 10
8
White Black Hispanic Asian/PI AI/AN
National and state distribution, 2004 By race/ethnicity, 2003
PI = Pacific Islander; AI/AN = American Indian or Alaskan Native.Data: Nursing Home Minimum Data Set (AHRQ 2005a, AHRQ 2005b).
Percent of nursing home residents who were physically restrained
States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: PATIENT-CENTERED, TIMELY CARE
45
SECTION 3. ACCESS
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS
46
Access includes indicators organized into two groups:
– Universal participation
– Affordable care
The Scorecard scores each group of indicators separately, and then averages the two scores to create the overall score for Access.
Universal Participation
Scored Indicators:
1. Adults under 65 insured all year, not underinsured
2. Adults with no access problem due to costs
Other Indicator:
1. Uninsured under 65: national and state trends
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: UNIVERSAL PARTICIPATION
47
Adults Ages 19–64 Who Are Uninsured and Underinsured,by Poverty Status, 2003
65
83
32
4
19
2613
499
0%
20%
40%
60%
80%
100%
Total 200% of poverty or more Under 200% of poverty
Insured, not underinsured Underinsured* Uninsured during year
* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income; medical expenses equaled 5% or more of incomes if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Data: 2003 Commonwealth Fund Biennial Health Insurance Survey (Schoen et al. 2005b).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: UNIVERSAL PARTICIPATION
48
* Did not get medical care because of cost of doctor’s visit, skipped medical test, treatment, or follow-up because of cost, or did not fill Rx or skipped doses because of cost.UK=United Kingdom; CAN=Canada; AUS=Australia; NZ=New Zealand; US=United States.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).
9
17
2934
40
0
40
80
UK CAN AUS NZ US
Percent of adults who had any of three access problems* in past year because of costs
Access Problems Because of Costs in Five Countries, Total and by Income, 2004
12
26
35
44
57
612
2429
25
UK CAN AUS NZ US
Below average income Above average income
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: UNIVERSAL PARTICIPATION
49
Population Under Age 65 Without Health Insurance
18
12
16
21
11
18
0
10
20
30
All under 65 Children under 18 Adults 18–64
2000 2005
Data: Analysis of Current Population Survey, March 1995–2005 supplements; P. Fronstin. 2005. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2005 Current Population Survey. Employee Benefit Research Institute (Figures 1, 2, and 3).
Percent uninsured
9 9 9 9 8 8 8
30 31 32 35 36 37 38
0
20
40
60
1999 2000 2001 2002 2003 2004 2005
Adults 18–64
Children under 18
Millions uninsured
39 40 4143 45 4645
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: UNIVERSAL PARTICIPATION
50
Percent of Adults Ages 18–64 Uninsured by State
Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute.
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
MARI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DE
DC
HI
CO
GAMS
OK
NJ
SD
19%–22.9%
Less than 14%
14%–18.9%
23% or more
1999–2000 2004–2005
MA
RI
CT
VTNH
MD
NH
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: UNIVERSAL PARTICIPATION
51
Affordable Care
Scored Indicators:
1. Families spending less than 10% of income or less than 5% of income, if low-income, on out-of-pocket medical costs and premiums
2. Population under 65 living in states where premiums foremployer-sponsored health coverage are less than 15% of under-65median household income
3. Adults under 65 with no medical bill problems or medical debt
Other Indicator:
1. Health insurance premium trends compared to workers’ earnings and overall inflation
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: AFFORDABLE CARE
52
Families with High Medical and Premium CostsCompared with Income, by Family Income, 2001–2002
13
34
2013
40
25
50
All incomes Under 100% ofpoverty
100%–199% ofpoverty
200%–399% ofpoverty
400%+ of poverty
Spent 5% to <10% of income, if low-income*
Spent >10% of income
Percent of nonelderly families with high out-of-pocketmedical costs and premiums relative to income
* Low-income denotes families with incomes <200% of the federal poverty level.Data: 2001–2002 Medical Expenditure Panel Survey (Merlis 2006).
17
46
38
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: AFFORDABLE CARE
53
Employer Premiums as Percentage of Median Household Incomefor Under-65 Population, Distribution by State
15 1513
12
1718
0
15
30
Single household Families
Median 10th %ile states 90th %ile states
Premiums for private coverage aspercent of median income per state
Data: State averages private premium rates—2003 Medical Expenditure Panel Survey;State median household incomes, under-65 population—2004–2005 Current Population Survey.
Premium 18%+ of income
9%
Premium 15%–17.9% of income
32%
Premium 12%–14.9% of income
57%
Premium <12% of income
2%
Under-65 population by premiumsas share of state median income
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: AFFORDABLE CARE
54
34
26
38
21
53 53
59
0
40
80
Total Income<$40,000
Income$40,000+
All Insured all year Uninsured during year
47
38
38
44
16
25
33
29
0 40 80
<200% of poverty
200%–399% of poverty
400%+ of poverty
Other
Asian/PI
Hispanic
Black
White
Medical Bill Problems or Accrued Medical Debt, 2005
Percent of adults (ages 19–64) with any medical bill problem or outstanding debt*
* Problems paying or unable to pay medical bills, contacted by a collection agency for inability to pay medical bills (only), had to change way of life to pay bills, or has medical debt being paid off over time.PI = Pacific Islander.Data: Analysis of 2005 Commonwealth Fund Biennial Health Insurance Survey; Collins et al. 2006.
By income and insurance status By race/ethnicity and income
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: AFFORDABLE CARE
55
* Estimate is statistically different from the previous year shown at p<0.05.^ Estimate is statistically different from the previous year shown at p<0.1.Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. Historical estimates of workers’ earnings have been updated to reflect new industry classifications (NAICS).Data: KFF/HRET Survey of Employer-Sponsored Health Benefits: 2005.
12.0
18.0
0.8
13.9^
12.9*10.9*
8.2*
5.3*
11.2*
8.59.2*
0
5
10
15
20
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Health insurance premiums
Workers' earnings
Overall inflation
Increases in Health Insurance PremiumsCompared with Other Indicators, 1988–2005
Percent
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
ACCESS: AFFORDABLE CARE
56
SECTION 4. EFFICIENCY
Scored Indicators:
1. Potential overuse or waste• Duplicate medical tests• Tests results or records not available at time of appointment• Received imaging study for acute low back pain with no risk factors
2. ER use for condition that could have been treated by regular doctor
3. Hospital admissions for ambulatory care sensitive (ACS) conditions• National ACS admissions: CHF, diabetes, and pediatric asthma• Medicare ACS admissions
4. Medicare hospital 30-day readmission rates
5. Medicare costs of care and mortality for AMI, colon cancer, hip fracture
6. Medicare costs of care for chronic diseases: diabetes, CHF, COPD
7. National health expenditures spent on health administration and insurance
8. Physicians using electronic medical records
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
57
International Comparison of Spending on Health, 1980–2004
0
1000
2000
3000
4000
5000
6000
7000 United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Data: OECD Health Data 2005 and 2006.
0
2
4
6
8
10
12
14
16
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Average spending on healthper capita ($US PPP)
Total expenditures on healthas percent of GDP
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
58
6
9 10 11
1820
0
20
40
UK NZ CAN AUS US GER
15
2523
12
21
16
23
White Black Hispanic Aboveaverageincome
Belowaverageincome
Insured Uninsured
International comparison United States, by race/ethnicity,income, and insurance status
Duplicate Medical Tests, Among Sicker Adults, 2005
Percent reporting that doctor ordered test that had already been done in past two years
UK=United Kingdom; NZ=New Zealand; CAN=Canada; AUS=Australia; US=United States; GER=Germany.Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
59
11 12
16 16
19
23
0
20
40
GER AUS NZ UK CAN US
20
3028
18
27
21
30
White Black Hispanic Aboveaverageincome
Belowaverageincome
Insured Uninsured
International comparison United States, by race/ethnicity,income, and insurance status
Percent reporting test results/records not available at time of appointment in past two years
Test Results or Medical Record Not Available atTime of Appointment, Among Sicker Adults, 2005
GER=Germany; AUS=Australia; NZ=New Zealand; UK=United Kingdom; CAN=Canada; US=United States.Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
60
Managed Care Health Plans: Potentially InappropriateImaging Studies for Low Back Pain, by Plan Type, 2004
18
15
2522
33
28
0
20
40
Private Medicaid
10th percentile Mean 90th percentile
Percent of health plan members (ages 18–50) who received an imaging study within 28 days following an episode of acute low back pain with no risk factors
Data: Health Plan Employer Data and Information Set (NCQA 2005a, 2005b).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
61
69
1215
21
26
0
25
50
GER NZ UK AUS CAN US
23
41
24
20
29
23
36
White Black Hispanic Aboveaverageincome
Belowaverageincome
Insured Uninsured
International comparison United States, by race/ethnicity,income, and insurance status
Went to ER for Condition That Could Have Been Treatedby Regular Doctor, Among Sicker Adults, 2005
Percent of adults who went to ER in past two years for condition that could have been treatedby regular doctor if available
GER=Germany; NZ=New Zealand; UK=United Kingdom; AUS=Australia; CAN=Canada; US=United States.Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
62
Ambulatory Care Sensitive (Potentially Preventable)Hospital Admissions for Select Conditions, 2002
498
241188
258
13774
631
299 297
0
100
200
300
400
500
600
700
Congestive heart failure Diabetes Pediatric asthma
National average Top 10% states Bottom 10% states
Adjusted rate per 100,000 population
* Combines four diabetes admission measures: uncontrolled, short-term complications, long-term complications, and lower extremity amputations. Data: National estimates—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; State estimates—State Inpatient Databases; not all states participate in HCUP (AHRQ 2005a).
*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
63
Medicare Discharges for Ambulatory Care Sensitive Conditions,Rates and Associated Costs, by Hospital Referral Regions, 2003
771
499
610
887
1043
0
300
600
900
1200
Nationalmean
10th 25th 75th 90th
13%
10%
12%
15%
16%
0%
10%
20%
Nationalmean
10th 25th 75th 90th
Rate of ACS discharges per 10,000 beneficiaries Costs of ACS discharges as percent of all discharge costs, average in region groups
Percentiles Percentiles
Data: G. Anderson and R. Herbert, Johns Hopkins University analysisof 2003 Medicare Standard Analytical Files (SAF) 5% Inpatient Data.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
64
Medicare Hospital 30-Day Readmission Rates and Associated Costs,by Hospital Referral Regions, 2003
18
1416
2022
0
5
10
15
20
25
30
Nationalmean
10th 25th 75th 90th
35
24
30
34
45
0
10
20
30
40
50
Nationalmean
1 2 3 4
Rate of hospital readmission within 30 days
Readmission reimbursement as percent of total reimbursement for all admissions
Quartile of regions rankedby readmission rates
Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2003 Medicare Standard Analytical Files (SAF) 5% Inpatient Data.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
65
Percentiles
0.80
0.90
1.00
1.10
1.20
$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000
Relative Resource Use**
Qu
alit
y o
f C
are*
(1
Yea
r S
urv
ival
In
dex
, M
edia
n =
70%
)
* Indexed to risk-adjusted 1 year survival rate (median = 0.70).** Risk-adjusted spending on hospital and physician services using standardized national prices.Data: E. Fisher and D. Staiger, Dartmouth College analysis of data from a 20% national sample of Medicare beneficiaries.
Quality and Costs of Care for Medicare Patients Hospitalizedfor Heart Attacks, Colon Cancer, and Hip Fracture,
by Hospital Referral Regions, 2000–2002
Median relative resource use = $25,994
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
66
Quality and Costs of Care for Medicare Patients Hospitalizedfor Heart Attacks, Colon Cancer, and Hip Fracture,
by Hospital Referral Regions, 2000–2002
323130
2827
30
Mean ofhighest
90%
10th 25th Median 75th 90th
1 year mortality rate Annual relative resource use*
* Risk-adjusted spending on hospital and physician services using standardized national prices.Data: E. Fisher and D. Staiger, Dartmouth College analysis of data from a 20% national sample of Medicare beneficiaries.
$29,047$27,465
$25,994$24,623
$23,314
$26,829
Mean ofhighest
90%
10th 25th Median 75th 90th
Deaths per 100 Dollars ($)
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
67
Percentiles Percentiles
Costs of Care for Medicare Beneficiaries withMultiple Chronic Conditions, by Hospital Referral Regions, 2001
Average annual reimbursementRatio of percentile
groups
Average10th
percentile25th
percentile75th
percentile90th
percentile90th to
10th75th to
25th
All 3 conditions
(Diabetes + CHF+ COPD)
$31,792 $20,960 $23,973 $37,879 $43,973 2.10 1.58
Diabetes + CHF $18,461 $12,747 $14,355 $20,592 $27,310 2.14 1.43
Diabetes + COPD $13,188 $8,872 $10,304 $15,246 $18,024 2.03 1.48
CHF + COPD $22,415 $15,355 $17,312 $25,023 $32,732 2.13 1.45
CHF = Congestive heart failure; COPD = Chronic obstructive pulmonary disease.Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2001 Medicare Standard Analytical Files (SAF) 5% Inpatient Data.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
68
Percentage of National Health ExpendituresSpent on Health Administration and Insurance, 2003
a 2002 b 1999 c 2001* Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance.Data: OECD Health Data 2005.
Net costs of health administration and health insurance as percent of national health expenditures
1.9 2.1 2.12.6
3.34.0 4.1 4.2
4.8
5.6
7.3
0
2
4
6
8
a b c *
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
69
Physicians’ Use of Electronic Medical Records,U.S. Compared with Other Countries, 2001
90 88
6258 56 55
5248
4237
30 29 2825
17 17 149
6 5
0
50
100
Percent of physicians
* 2000Data: 2001 European Union EuroBarometer and 2000 Commonwealth Fund International Health Policy Survey of Physicians (Harris Interactive 2002).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
70
SECTION 5. EQUITY
For equity, the Scorecard contrasts rates of risk by insurance, income, and race/ethnicity. Specifically, the risk ratios compare:
– Insured to uninsured rates– High-income to low-income rates– White to black rates– White to Hispanic rates
Indicators used to score equity include a subset of main indicators and a few equity-only indicators to highlight certain areas of concern. They are grouped as follows:
– Long, healthy & productive lives– The right care– Safe care– Patient-centered, timely care– Coordinated and efficient care– Universal participation and affordable care
Charts for equity indicators are interspersed throughout other sections as appropriate.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY
71
5.0
7.9
4.8
5.6
5.8
8.6
13.9
7.0
0 10 20
At least some college
Less than high school
AI/AN
Asian/PI
Hispanic
Black
White
U.S. National
Infant Deaths Within One Year, per 1,000 Live Births
19.1
13.9
15.2
8.69.2
5.8
9.5
5.6
8.3
4.8
0
10
20 White BlackHispanic Asian/PIAI/AN
Infant mortality by race/ethnicity,and mother’s education, 2002
Infant mortality trends, 1983–2002
* For mothers age 20 and older.PI = Pacific Islander; AI/AN = American Indian or Alaskan Native.Data: National Vital Statistics System—Linked Birth and Infant Death Data (AHRQ 2005a; NCHS 2005).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
72
*
Five-Year Survival Rates for All Cancers,by Gender, Race/Ethnicity, and Census Tract Poverty Rate
White Black Hispanic Asian AI/AN
TOTAL (1988–1997)
Men 55 46 53 50 40
Women 58 47 57 61 47
MEN (1988–1994)
Low poverty, <10% 61 58 60 55 38
High poverty, 20%+ 52 45 54 44 42
WOMEN (1988–1994)
Low poverty, <10% 63 58 65 66 44
High poverty, 20%+ 55 48 60 56 53
Note: Low poverty denotes census tracts where less than 10% of households have incomes below the federal poverty level in 1990; high poverty denotes census tracts where 20% or more of households have incomes below the federal poverty level in 1990. AI/AN = American Indian or Alaskan Native.Data: Surveillance, Epidemiology, and End Results (SEER) Program(Total estimates—Clegg 2002; Poverty estimates—Singh 2003).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
73
Stage at Diagnosis and Five-Year Survival Rate for Breast Cancerand Colorectal Cancer, by Race/Ethnicity, 1988–1997
63
82
52
68
56
78
66
85
50
69
0
50
100
Localized stage atdiagnosis
5-year survival rate
AI/AN = American Indian or Alaskan Native.Data: Surveillance, Epidemiology, and End Results (SEER) Program (Clegg 2002).
Percent
60 59
52 5156 55
65 63
46
58
Females Males
Female breast cancer Five-year survival rates for colorectal cancer, by gender
White Black Hispanic Asian AI/AN
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
74
32
104
99
139
171
172
223
120
0 50 100 150 200 250
At least some college
Less than high school
AI/AN
Asian/PI
Hispanic
Black
White
U.S. National
* Total of 43 reporting states and D.C. for people ages 25–64.PI = Pacific Islander; AI/AN = American Indian or Alaskan Native.Data: National Vital Statistics System—Mortality (Retrieved from DATA2010 at http://wonder.cdc.gov/data2010).
17
63
58
96
70
109
138
78
0 50 100 150 200
Coronary Heart Disease and Diabetes-Related Mortality,by Race/Ethnicity and Education Level, 2003
Coronary heart disease deaths Diabetes-related deaths
Age-adjusted per 100,000 population
*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
75
4043
34
27
21
45
3632
43
37
18
0
30
60
3840
28
2225
45
38
31
Receipt of Recommended Preventive Care for Older Adults,by Race/Ethnicity, Family Income, and Insurance Status, 2002
Percent of older adults who received all recommended screening andpreventive care within a specific time frame given their age and sex*
Adults ages 50–64 Adults ages 65+
* Recommended care includes seven key screening and preventive services: blood pressure,cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: THE RIGHT CARE
76
1714
3534
12
28
22
18
28
33
13
33
0
25
50
Total
White
Black
Mexican
NonpoorPoor*
24
19
42
36
16
40
Total
White
Black
Mexican
NonpoorPoor*
Children ages 6–17 Adults ages 18–64 Adults ages 65–74
Untreated Dental Caries, by Age, Race/Ethnicity,and Income, 1999–2002
Percent of persons with untreated dental caries
*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: THE RIGHT CARE
77
* Nonpoor refers to household incomes >200% of federal poverty level; Poor to <100% of poverty level.Data: National Health and Nutrition Examination Survey (NCHS 2005).
26 25 2622
25
30
21
34
18
27
0
25
50
71 69 72
83
68 7074 72
0
50
100
Adults with Poorly Controlled Chronic Diseases, by Race/Ethnicity, Family Income, and Insurance Status, 1999–2002
Percent of adults (ages 18+) with diagnosed diabetes with HbA1c level >9%
Percent of adults (ages 18+) with hypertension with blood pressure >140/90 mmHg
* ** *
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: THE RIGHT CARE
78
* High refers to household incomes >400% of federal poverty level; Middle to 200%–399% of poverty; Near Poor to 100%–199% of poverty; and Poor to <100% of poverty.** Data by insurance was from 1988–1994; HbA1c level >9.5%.Data: National Health and Nutrition Examination Survey (AHRQ 2005a, Saaddine 2002).
Receipt of All Three Recommended Services for Diabetics,by Race/Ethnicity, Family Income, Insurance, and Residence, 2002
45
55
54
46
50
61
55
53
54
47
24
38
0 50 100
Rural
Urban
Uninsured
Private
<100% of poverty
100%–199% of poverty
200%–399% of poverty
400%+ of poverty
Hispanic
Black
White
Total
Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year
* Insurance for people ages 18–64.** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants.Data: 2002 Medical Expenditure Panel Survey (AHRQ 2005a).
*
**
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: THE RIGHT CARE
79
Select AHRQ Patient Safety Indicators, 2002
Risk adjusted rate per 1,000 discharges* Failure to rescue Decubitus ulcers
Selected infections due to medical care
Postoperative pulmonary embolus or deep vein thrombosis
Postoperative sepsis
RACE/ETHNICITYWhite 141.6 22.4 2.2 7.9 11.1Black 141.3 35.2 3.3 12.0 16.2Hispanic 146.3 25.3 2.1 7.4 13.1Asian/Pacific Islander 155.6 19.9 2.5 5.4 12.6
MEDIAN INCOME OF PATIENT ZIPCODELess than $25,000 128.9 28.0 2.4 9.4 13.8$45,000 or more 136.4 23.8 2.4 8.8 11.1
INSURANCEPrivate insurance 128.5 20.3 1.9 7.5 9.4Uninsured/self pay 151.3 19.4 1.5 7.6 10.5
PATIENT RESIDENCEUrban 138.8 26.2 2.5 9.4 12.8Rural 124.8 18.7 1.7 6.8 10.0
* Rates exclude complications present on admission and are adjusted for gender, comorbidities, and diagnosis-related group clusters. See Technical Appendix for details.Data: Income Area, Insurance, and Residence estimates—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; Race/Ethnicity estimates—HCUP, State Inpatient Database (AHRQ 2005a, 2005b).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: SAFE CARE
80
2320
2931
14
27
18
38
0
25
50
Total White Black Hispanic Aboveaverage
Belowaverage
Insured Uninsured
Race/ethnicity Income Insurance status
Waiting Time to See Doctor When Sick by Race/Ethnicity,Income, and Insurance Status, 2005
Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults.
Percent of adults who reported waiting six or more days for an appointment when sick or needed medical attention
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: PATIENT-CENTERED, TIMELY CARE
81
Doctor–Patient Communication by Race/Ethnicity, Family Income, Insurance, and Residence, 2002
Percent of adults (ages 18+) reporting health providers “sometimes” or “never” listen carefully, explain things clearly, respect what they say, and spend enough time with them
* Insurance for people ages 18–64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants.AI/AN = American Indian or Alaskan Native.Data: 2002 Medical Expenditure Panel Survey (AHRQ 2005a).
1112
1910
16
18
1612
11
15
9
10
0 10 20
Rural
Urban
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
AI/AN
Asian
Hispanic
Black
White
Total
*
**
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: PATIENT-CENTERED, TIMELY CARE
82
Having an Accessible Primary Care Provider, by Age Group, Race/Ethnicity, and Insurance Status, 2002
83
7176
62
75
49
0
50
100
Ages 65+ years Ages 19-64 years
White Black Hispanic
7672
66
52
42
33
White Black Hispanic
Insured all year Uninsured part or all year
Nonelderly adults ages 19–64
Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.
Percent of adults with a usual source of care who provides preventive care, care for new and ongoing health problems, and referrals, and who is easy to get to
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: COORDINATED AND EFFICIENT CARE
83
Diabetes*
144
527
185135
345
Congestive heart failure Pediatric asthma
180
690
426
188
450
240
530
422
780
0
400
800
Adjusted rate per 100,000 population
Ambulatory Care Sensitive (Potentially Preventable) Hospital Admissions, by Race/Ethnicity and Patient Income Area, 2002
* Combines 4 diabetes admission measures: uncontrolled, short-term complications, long-term complications, and lower extremity amputations. Data: Race/ethnicity estimates—Healthcare Cost and Utilization Project, State Inpatient Databases (disparities analysis files) and National Hospital Discharge Survey (AHRQ 2005a, 2005b); Income area estimates—HCUP, Nationwide Inpatient Sample (AHRQ 2005a). Patient Income Area = median income of patient zip code. NA = data not available.
NA
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: COORDINATED AND EFFICIENT CARE
84
Nonelderly Adults with Time Uninsured During the Year,by Race/Ethnicity and Family Income, 2002
Percent of nonelderly adults (ages <65) who had no health insurance coverage sometime during the year
* High refers to household incomes >400% of federal poverty level; Poor to <100% of poverty.Data: 2002 Medical Expenditure Panel Survey (AHRQ 2005b).
26
21
28
44
23
12 11
16
23
13
43 42
33
54
41
0
30
60
Total White Black Hispanic Asian
Total High income Poor*
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: UNIVERSAL PARTICIPATION AND AFFORDABLE CARE
85
Cost-Related Access Problems, by Race/Ethnicity, Income,and Insurance Status, 2005
59
28
40
23
41
36
36
50
44
37
0 50 100
Uninsured during year
Insured all year
<200% of poverty
200%–399% of poverty
400%+ of poverty
Other
Hispanic
Black
White
Total
Percent of adults (ages 19–64) who had any of four access problems* in past year because of cost
* Did not fill a prescription; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor or clinic; or did not see a specialist when needed.Data: Analysis of 2005 Commonwealth Fund Biennial Health Insurance Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EQUITY: UNIVERSAL PARTICIPATION AND AFFORDABLE CARE
86
SECTION 6. SYSTEM CAPACITY TO INNOVATE AND IMPROVE
The Scorecard addresses but does not score indicators for system capacity to innovate and improve.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
SYSTEM CAPACITY TO IMPROVE
87
Hospital Nursing Staff Vacancy Rates, 2000
10
15 14
12
10
1211
9 9
0
5
10
15
20
Nationalaverage
Criticalcare
Medical/Surgical
ER Obstetrics West South Northeast Midwest
Percent
Data: American Organization of Nurse Executives 2000 Acute Care Hospital Survey of RN Vacancies and Turnover Rates.
Type of acute care Region
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
SYSTEM CAPACITY TO IMPROVE
88
Nursing Homes: Turnover Rates of Certified Nursing Aidesin Nursing Homes, 2002
71
21
38
119
136
0
50
100
150
National average Lowest state Lowest 10%states
Highest 10%states
Worst state
Rate of terminations to established positions
Data: 2002 American Health Care Association Survey of Nursing Staff Vacancy and Turnover in Nursing Homes (AHCA 2002).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
SYSTEM CAPACITY TO IMPROVE
89
National Health Expenditures Invested in Research and Spenton Public Health Activities Compared with Administration and Insurance
Costs, 2000 and 2004
1.9
3.2
6.0
2.1
3.0
7.3
0
2
4
6
8
Investment inresearch
Governmentpublic health
activities
Administrationand insurance
costs
2000 2004
Data: CMS Office of the Actuary, National Health Statistics Group; and U.S. Dept. of Commerce, Bureau of Economic Analysis and U.S. Bureau of the Census (Smith et al. 2006).
25.6
43.4
81.2
39.0
56.1
136.7
0
50
100
150
Investment inresearch
Governmentpublic health
activities
Administrationand insurance
costs
2000 2004
Dollars (in billions) Percent of national health expenditures
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
SYSTEM CAPACITY TO IMPROVE
90
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
Scorecard-Related Publications
• Cathy Schoen, Karen Davis, Sabrina K. H. How, and Stephen C. Schoenbaum, “U.S. Health System Performance: A National Scorecard,” Health Affairs Web Exclusive (Sept. 20, 2006):w457–w475. Available online at: http://content.healthaffairs.org/cgi/reprint/25/5/w457
• Commonwealth Fund Publications:
– Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance (Sept. 2006).
– Cathy Schoen and Sabrina K. H. How, National Scorecard onU.S. Health System Performance: Technical Report (Sept. 2006).
– Cathy Schoen and Sabrina K. H. How, National Scorecard onU.S. Health System Performance: Complete Chartpack and Chartpack Technical Appendix (Sept. 2006).
These Fund publications are available for free download onThe Commonwealth Fund’s Web site at www.cmwf.org.
91
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