National Scorecard, 2008: Chartpack This Chartpack presents data for all indicators scored in the National Scorecard on U.S. Health System Performance,

National Scorecard, 2008: Chartpack

This Chartpack presents data for all indicators scoredin the National Scorecard on U.S. Health System Performance, 2008. Charts display average performance for the U.S. as a whole and the range of performance found within the U.S or compared with other countries.

The charts accompany the Commission’s July 2008 report, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, 2008.

Scores: Dimensions of a High Performance Health System

75

72

67

52

70

67

72

71

58

53

71

65

0 100

Healthy Lives

Quality

Access

Efficiency

Equity

OVERALL SCORE

2006 Revised

2008

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 2

HEALTHY LIVES

SECTION 1. HEALTHY 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*

* Indicator was not updated due to lack of data. Baseline figures from 2006 Scorecard are presented.


7681

88 8489 89

99 9788

97

109 106116 115 113

130134

128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150 1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See report Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).

Mortality Amenable to Health Care

HEALTHY LIVES


7.2 7.0 6.9 6.8 7.0 6.8 6.8

10.311.1

10.2 9.9 9.9 9.610.1

5.3 5.1 5.0 4.9 4.8 4.7 4.7

0

4

8

12

1998 1999 2000 2001 2002^ 2003 2004

U.S. average Bottom 10% states Top 10% states

National Average and State Distribution International Comparison, 2004

2.8 2.8 3.1 3.2 3.3

4.4

5.3

6.8


Infant Mortality Rate

Infant deaths per 1,000 live births

^ Denotes baseline year.Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003, 2004, 2005, 2006, 2007a); international comparison—OECD Health Data 2007, Version 10/2007.

HEALTHY LIVES

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

Note: Indicator was not updated due to lack of data. Baseline figures are presented. 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


HEALTHY LIVES

Working-Age Adults with Health Limits on Activities or Work

Data: D. Belloff, Rutgers Center for State Health Policy analysis of Behavioral Risk Factor Surveillance System.

7

Percent of adults (ages 18–64) limited in any activities because of physical, mental, or emotional problems

8.3

13.4

24.2

10.3

15.4

27.4

Age 18–29 Age 30–49 Age 50–64

2004 2006

14.9

11.5

20.117.5

13.2

23.4

0

10

20

30

40

U.S. Average Top 10% States Bottom 10%States

2004 2006


National Average and State Distribution By Age Group

HEALTHY LIVES

Note: Indicator was not updated due to lack of data. Baseline figures from Scorecard 2006 are presented. Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and AdolescentHealth 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


HEALTHY LIVES

http://www.nschdata.org/


SECTION 2. QUALITY

Quality includes indicators organized into four groups:

1. Effective care

2. Coordinated care

3. Safe care

4. 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


Effective 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 heart attack, heart failure, and pneumonia

QUALITY: EFFECTIVE CARE



32

46

53

47

49

50

58

39

0 20 40 60 80 100

Uninsured all year

Uninsured part year

Insured all year

<200% of poverty

200%–399% of poverty

400%+ of poverty

2005

2002


Receipt of Recommended Screening and Preventive Care for Adults

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. See report Appendix B for complete description.Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.

U.S. Variation 2005

U.S. Average


Immunizations for Young Children

^ Denotes baseline year.* 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. **Data by insurance was from 2003.Data: National Immunization Survey (NCHS National Immunization Program, Allred 2007).

Percent of children (ages 19–35 months) who received all recommended doses of five key vaccines*

73 74 7579 81 81 8182 80

8489 88 88 86

66 66 6571 72 71 72

0

25

50

75

100

2000 2001 2002 2003^ 2004 2005 2006

U.S. average Top 10% states Bottom 10% states


By Family Income, Insurance Status**, and Race/Ethnicity, 2006

71

75

83

82

77

80

77

82

0 25 50 75 100

Uninsured all year

Insured part year

Insured all year

100%+ of poverty

<100% of poverty

Hispanic

Black

White


National Average and State Distribution

Percent of children (ages <18) who 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 20 40 60 80 100

Uninsured

Private insurance

<100% of poverty

400%+ of poverty

Hispanic

Black

White

Bottom 10% states

Top 10% states

U.S. average

Note: Indicator was not updated due to lack of data. Baseline figures from 2006 Scorecard are presented. Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and AdolescentHealth database at http://www.nschdata.org).





50

87

80

52

69

60

71

73

65

0 20 40 60 80 100

Uninsured

Medicare**

Medicaid

Private

Hispanic

Black

White

2006

2004


Adults with Major Depressive Episode Who Received Treatment

U.S. Variation 2006

U.S. Average


Percent of adults (ages 18+) with major depressive episode who received treatment in the past year*

Note: Indicator definition has been modified from 2006 Scorecard.*Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms for depression. **Medicare includes other insurance such as military and veterans health care.Data: National Survey on Drug Use and Health (SAMHSA 2006 and 2007).

Note: Indicator was not updated due to lack of data. Baseline figures are presented. * 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 20 40 60 80 100

Uninsured

Private insurance

<100% of poverty

400%+ of poverty

Hispanic

Black

White

Bottom 10% states

Top 10% states

U.S. average





Chronic Disease Under Control: Diabetes and Hypertension

81

41

63

21

Diabetes under

control*

High blood pressure

under control**

Insured Uninsured

*Refers to diabetic adults whose HbA1c is <9.0 **Refers to hypertensive adults whose blood pressure is <140/90 mmHg. Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.

79

31

88

41

0

25

50

75

100

Diabetes under

control*

High blood pressure

under control**

1999-2000 2003-2004

Percent of adults (age 18+)

National Average By Insurance, 1999-2004



Chronic Disease Under Control: Managed Care Plan Distribution, 2006

70 73

49

81

88

68

6056

30

0

25

50

75

100

Private Medicare Medicaid

Mean 90th %ile 10th %ile

Note: Diabetes includes ages 18–75; hypertension includes ages 18–85.Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).

Percent of adults with diagnosed diabetes whose HbA1c level <9.0%



6057

53

68 67 66

4946

39

0

25

50

75

100



Percent of adults with hypertension whose blood pressure <140/90 mmHg

Diabetes Hypertension

9691

87

99 9895

88

7176

Heart Attack Heart Failure Pneumonia

Median 90th %ile 10th %ile

84

99

91

75

90

10096

78

0

25

50

75

100

Median Best 90th %ile 10th %ile

2004 2006

Overall Composite for All Three Conditions


Hospitals: Quality of Care for Heart Attack, Heart Failure, and Pneumonia

* Composite for heart attack care consists of 5 indicators; heart failure care, 2 indicators; and pneumonia care, 3 indicators.Overall composite consists of all 10 clinical indicators. See report Appendix B for description of clinical indicators.Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.

Percent of patients who received recommended care for all three conditions*

Individual Composites by Condition, 2006

Percent of patients who received recommended care for each condition*


87

74

91 8982

94100

0

25

50

75

100

Median Best 90th %ile 10th %ile Best 90th %ile 10th %ile

Percent of patients who received recommended care for all three conditions

Hospital Quality of Care for Heart Attack, Heart Failure, and Pneumonia: Overall Composite Using Expanded Set of 19 Clinical Indicators*, 2006

*Consists of original 10 "starter set" indicators and 9 new indicators for which data was made available as of December 2006; heart attack care includes 3 new indicators; heart failure care, 2 new indicators; and pneumonia, 4 new indicators)Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.

Hospitals States



Hospital Quality of Care by Condition: Composites for Heart Attack, Heart Failure, and Pneumonia

HOSPITALS STATES

Percent of patients who received recommended care:

Median Best90th

percentile10th

percentileBest

90th percentile

10th percentile

Acute myocardial infarction

(Original: 5 indicators)

2004

2006

92

96

100

100

98

99

80

88

97

98

96

97

89

93

(Expanded: 8 indicators*) 2006 95 100 98 87 98 97 92

Heart failure


2004

2006

83

91

100

100

94

98

62

71

91

94

89

93

79

81


Pneumonia


2004

2006

78

87

99

100

88

95

66

76

82

92

79

91

69

83


20Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 20


*Consists of original "starter set" indicators and new indicators for which data was made available as of December 2006.Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.

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

5. Home health: hospital admissions

QUALITY: COORDINATED CARE



37

51

74

63

69

65

66

49

53

73

59

0 20 40 60 80 100

Uninsured all year

Uninsured part year

Insured all year

<200% of poverty


400%+ of poverty

Hispanic

Black

White

2005

2002

U.S. Variation 2005

U.S. Average


Percent of adults ages 19–64 with an accessible primary care provider*


Adults with an Accessible Primary Care Provider

* An accessible primary care provider is defined as a usual source of care who provides preventive care, care for new and ongoing health problems, referrals, and who is easy to get to.Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.

Note: Indicator was not updated due to lack of data. Baseline figures are presented. * Child had 1+ preventive visit in past year; access to specialty care; personal doctor/nurse who usually/always spent enoughtime 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 AdolescentHealth database at http://www.nschdata.org).

23

53

58

39

53

36

60

46

30

31

0 20 40 60 80 100

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*





86

7773 72 69 67

0

25

50

75

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, 2005

Note: Indicator was not updated due to lack of data. Baseline figures from Scorecard 2006 are presented. AUS=Australia; CAN=Canada; GER=Germany; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2005 Commonwealth Fund International Health Policy Survey.



50

87

9

49

61

33

68 69

80

56

36

94

0

25

50

75

100

U.S. mean 90th %ile 10th %ile Median 90th %ile 10th %ile

2004 2006

Percent of heart failure patients discharged home with written instructions*

Heart Failure Patients Given Complete Written Instructions When Discharged, by Hospitals and States


* 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: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare; State 2004 distribution —Retrieved from CMS Hospital Compare database at http://www.hospitalcompare.hhs.gov.

Hospitals States


http://www.hospitalcompare.hhs.gov/

Managed Care Health Plans: 30-Day Follow-Up After Hospitalization for Mental Illness

76

56 58

8881 80

63

29

17

0

25

50

75

100



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 76 76

59 61 61 60 61 5956

55 5256 56 55 57 58

2000 2001 2002 2003 2004* 2005 2006


Annual averagesManaged Care Plans (2006)

* Denotes baseline year.Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).



Nursing Homes: Hospital Admission and Readmission RatesAmong Nursing Home Residents

17

1315

1922

18

1516

2022

0

20

40

Median 10th

%ile

25th

%ile

75th

%ile

90th

%ile

2000 2004

17

1113

21

26

19

1214

23

27

0

20

40

Median 10th

%ile

25th

%ile

75th

%ile

90th

%ile

2000 2004


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 and 2004.

Percent of long-stay residents with a hospital admission

Percent of short-stay residents re-hospitalized within 30 days of hospital discharge to nursing home


Home Health Care: Hospital Admissions

28

17

47

20

35

28

19

48

20

37

0

20

40

60

Mean Top 25% Bottom 25% Top 10% Bottom 10%

2003-2004^ 2006-2007

^ 2003 data for state estimates. Data: Outcome and Assessment Information Set (Retrieved from CMS Home Health Compare database at http://www.medicare.gov/HHCompare, Pace et al. 2005)

Percent of home health care patients who had to be admitted to the hospital



Home Health Agencies States

http://www.medicare.gov/HHCompare

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. Surgical infection prevention

2. Adverse events and complications of care in hospitals

QUALITY: SAFE CARE


Medical, Medication, and Lab Errors, Among Sicker Adults

3432

1921 22

2628

30

0

10

20

30

40

GER NETH UK NZ CAN AUS

International Comparison

AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.

EXHIBIT 16

2005 2007

United States

QUALITY: SAFE CARE

Percent reporting medical mistake, medication error, or lab error in past two years


Ambulatory Care Visits for Treating Adverse Drug Effects

20

22

18

21

17

9

28

1716

22

0

10

20

30

* Denotes baseline year.Data: C. Zhan, AHRQ analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.

Visits per 1,000 population per year

QUALITY: SAFE CARE


11.312.9

15.3

11.3

17.4

19.8

1999 2000 2001* 2002 2003 2004

Total

Physician Office

Hospital Emergency Department Visits

Hospital Outpatient Department Visits

By Gender, Race, and Region, 2004 Annual Averages, by Care Setting

Potentially Inappropriate Antibiotic Prescribingfor Children with Sore Throat

Percent of children prescribed antibiotics for throat infection without receiving a “strep” test*

32

4335

0

25

50

75

100

1997-2003 2004

National Average Managed Care Plan Distribution, 2006

QUALITY: SAFE CARE


27

44

14

23

43

74

Private Medicaid


Note: National average includes ages 3–17 and plan distribution includes ages 2–18.* A strep test means a rapid antigen test or throat culture for group A streptococcus.Data: National average—J. Linder, Brigham and Women's Hospital analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey; Plan distribution—Healthcare Effectiveness Data and Information Set (NCQA 2007).

Inappropriate Use of Medications by Elderly

19

17

191819

0

10

20

30

2000 2001 2002* 2003 2004

Percent of community-dwelling elderly adults (ages 65+) who reported taking at least 1 of 33 drugs that are potentially inappropriate for the elderly

* Denotes baseline year.Data: Medical Expenditure Panel Survey (AHRQ 2007a).

QUALITY: SAFE CARE

13

20

17 17

1413

17

20

15

By Gender, Race/Ethnicity, and Region, 2004National Average


Pressure Sores Among High-Risk and Short-Stay Residentsin Nursing Facilities

13

8

18

13

7

17

0

10

20

30

U.S. average Top 10% states Bottom 10%states

2004 2006

Percent of nursing home residents with pressure sores

19

14

24

17

12

23

U.S. average Top 10% states Bottom 10%states

2004 2006

High-Risk Residents Short-Stay Residents

Data: Nursing Home Minimum Data Set (AHRQ 2005, 2007a).

QUALITY: SAFE CARE


Hospital-Standardized Mortality Ratios

101

8593 94 97 100 103 106 106

112118

8274 78 78 79 81 83 83 85 86 89

0

20

40

60

80

100

120

140

U.S. 1 2 3 4 5 6 7 8 9 10

2000-2002 2004-2006

Ratio of actual to expected deaths in each decile (x 100)

Decile of hospitals ranked by actual to expected deaths ratios

Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors.* Medicare national average for 2000=100

QUALITY: SAFE CARE

mean

* See report Appendix B for methodology.Data: B. Jarman analysis of Medicare discharges from 2000 to 2002 and from 2004 to 2006 for conditions leading to 80 percent of all hospital deaths.


80

60

90 87

73

92100

0

25

50

75

100

Median Best 90th %ile 10th %ile Best 90th %ile 10th %ile

Surgical Infection Prevention, 2006

Hospitals States


QUALITY: SAFE CARE

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

* Comprised of two indicators: antibiotics started within 1 hour before surgery and stopped 24 hours after surgery.Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.

Nosocomial Infections in Intensive Care Unit Patients, 2006

Central line-associated bloodstream infection rate, per 1,000 days use Percentile

Type of ICU No. of units 10% 25% 50% 75% 90%

Medical 73 0.0 0.0 2.2 4.2 6.2

Medical-surgical—major teaching 63 0.0 0.6 1.9 3.1 5.5

Medical-surgical—all others 102 0.0 0.0 1.0 2.3 4.5

Surgical 72 0.0 0.9 2.0 4.4 7.4

Neonatal–Level III(infants weighing 750 grams or less) 42 0.0 2.5 5.2 11.0 15.6

Ventilator-associated pneumonia rate, per 1,000 days use Percentile

Type of ICU No. of units 10% 25% 50% 75% 90%

Medical 64 0.0 0.9 2.8 4.6 7.2

Medical-surgical—major teaching 58 0.0 1.3 2.5 5.1 7.3

Medical-surgical—all others 99 0.0 0.0 1.6 3.8 6.2

Surgical 61 0.0 1.8 4.1 6.4 10.0

Neonatal (NICU)(infants weighing 750 grams or less) 36 0.0 0.0 1.7 4.1 9.5

Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007).

37

QUALITY: SAFE CARE


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 2004 2005

Decubitus ulcer (pressure sore)

National 195 221 236 248 261 NA

Medicare 206 225 251 267 276 282

Postoperative pulmonary embolismor deep vein thrombosis

National 58 66 79 86 89 NA

Medicare 62 71 86 92 98 100

Postoperative sepsis

National 63 81 92 92 105 NA

Medicare 80 97 111 120 131 121

Postoperative respiratory failure

National 63 72 80 86 82 NA

Medicare 25 34 46 50 53 59

Accidental puncture or laceration

National 38 44 47 47 48 NA

Medicare 31 32 36 34 34 35

Infection due to medical care

National 12 14 15 16 16 NA

Medicare 20 20 24 25 25 15

* 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. NA=data not available. Data: National figures—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at http://hcupnet.ahrq.gov); Medicare figures—MedPAC analysis of Medicare administrative data using AHRQ indicators and methods (MedPAC 2005, Chart 3-3 and 2007, Chart 4-2).

38

QUALITY: SAFE CARE


http://hcupnet.ahrq.gov/

Potentially Preventable Adverse Events and Complicationsof Care in Hospitals Among Medicare Beneficiaries, 2004–2005

2.4

9.8

4.6

1.9

8.8

3.63.6

10.6

6.0

0

5

10

15

Postoperative

complications composite*

Adverse drug events

composite**

Pressure sores

US Average Top 10% States Bottom 10% StatesPercent


QUALITY: SAFE CARE

*Surgical patients with postoperative pneumonia, urinary tract infection (2005 only), or venous thromboembolic event ** Patients with serious bleeding associated with intravenous heparin, low molecular weight heparin, or warfarin, or hypoglycemia associated with insulin or oral hypoglycemics.Data: M. Pineau, Qualidigm analysis of Medicare Patient Safety Monitoring System.

Patient-Centered, Timely Care

Scored Indicators:

1. Ability to see doctor on same/next day when sick or need 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

QUALITY: PATIENT-CENTERED, TIMELY CARE



Waiting Time to See Doctor When Sick or Need Medical Attention, Among Sicker Adults

47 46

7469

6358 57

32

0

25

50

75

100

NZ NETH GER AUS UK CAN



EXHIBIT 16

2005 2007

United States


Percent of adults who could get an appointment on the same or next day


Difficulty Getting Care on Nights, Weekends, Holidays WithoutGoing to the Emergency Room, Among Sicker Adults

61

73

48 49 50

6168 69

0

25

50

75

100

NETH NZ GER UK AUS CAN



Percent of adults who sought care reporting “very” or “somewhat” difficult


2005 2007

United States


Doctor–Patient Communication: Doctor Listened Carefully,Explained Things, Showed Respect, and Spent Enough Time,

National and Managed Care Plan Type

70 7067

75 74 73

65 6359

Private Medicare** Medicaid


43

Percent of adults (ages 18+) reporting “always”

Managed Care Plan Distribution, 2006

* Denotes baseline year. **2005 data due to delays in the Medicare CAHPS survey.Data: National average—Medical Expenditure Panel Survey (AHRQ 2005, 2006, 2007a); Plan distribution—CAHPS (data provided by NCQA).

5457 57

0

25

50

75

100

2002* 2003 2004

National Average



6558 56

5045

37

0

25

50

75

100

CAN US NZ AUS UK GER

Adults with Chronic Conditions: Receipt of Self-Management Plan, Among Sicker Adults, 2005

Note: Indicator was not updated due to lack of data. Baseline figures are presented. * Adult reported at least one of six conditions: hypertension, heart disease, diabetes, arthritis, lung problems (asthma, emphysema, etc.), or depression.AUS=Australia; CAN=Canada; GER=Germany; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2005 Commonwealth Fund International Health Policy Survey.

Percent of adults with chronic conditions* whose doctor gave plan to manage care at home



Patient-Centered Hospital Care: Staff Managed Pain, RespondedWhen Needed Help, and Explained Medicines, by Hospitals, 2007

6760 58

9791

96

75 7266

60

48 49

0

25

50

75

100

Staff managed pain well Staff responded when needed

help

Staff explained medicines and

side effects

Mean Best hospital 90th %ile hospitals 10th %ile hospitals

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 (Retrieved from CMS Hospital Compare database at http://www.hospitalcompare.hhs.gov).

*** ***

45



http://www.hospitalcompare.hhs.gov/

Physical Restraints in Nursing Facilities

9.7

8.0 7.4 6.85.9

18.4

3.72.6 2.4 2.2 1.9

11.7

13.214.114.7

0

5

10

15

20

2002 2003 2004 2005 2006

U.S. average Bottom 10% states Top 10% states

PI=Pacific Islander; AI/AN=American Indian or Alaskan Native.Data: Nursing Home Minimum Data Set (AHRQ 2004, 2005, 2006, 2007a).

7.86.9

10.7 10.2

7.66.6

5.8

8.79.8

7.7

White Black Hispanic Asian/PI AI/AN

2003 2005

By Race/Ethnicity



Percent of nursing home residents who were physically restrained

National Average and State Distribution

SECTION 3. ACCESS

Access includes indicators organized into two groups:

1. Participation

2. Affordability

The Scorecard scores each group of indicators separately, and then averages the two scores to create the overall score for Access.

ACCESS


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

ACCESS: PARTICIPATION


Uninsured and Underinsured Adults, 2007 Compared with 2003


Total 200% of poverty or moreUnder 200% of poverty

* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income, or 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Data: 2003 and 2007 Commonwealth Fund Biennial Health Insurance Survey.

Percent of adults (ages 19–64) who are uninsured or underinsured

26 28

49 48

13 16

914

19 24

411

0

25

50

75

100

2003 2007 2003 2007 2003 2007

Underinsured*

Uninsured during year

4235

17

27

6872


Access Problems Because of Costs

4037

58

12

21

25 26

0

25

50

NETH UK CAN GER NZ AUS


* 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.AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.

EXHIBIT 16

2005 2007

United States


Percent of adults who had any of three access problems* in past year because of costs


58

12

2125 26

37

0

25

50

75

NETH UK CAN GER NZ AUS US

69

1824

32 30

52

38 7

1822 21

25

NETH UK CAN GER AUS NZ US

Below average income Above average income

51

* 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.AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2007 Commonwealth Fund International Health Policy Survey.


Access Problems Because of Costs, By Income, 2007

Percent of adults who had any of three access problems* in past year because of costs


Data: Two-year averages 1999–2000, updated with 2007 Current Population Survey correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 CPS.

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 2005–2006

MA

RI

CT

VTNH

MD

Percent of Adults Ages 18–64 Uninsured by State



Data: Two-year averages 1999–2000, updated with 2007 Current Population Survey correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 CPS.

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

10%–15.9%

Less than 7%

7%–9.9%

16% or more

1999–2000 2005–2006

MA

RI

CT

VTNH

MD

Percent of Children Ages 0–17 Uninsured by State



Population Under Age 65 Without Health Insurance

17

12

16

20

12

18

0

10

20

30

All under 65 Children under 18 Adults 18–64

2000 2006

Percent uninsured

9 8 8 8 8 8 8 9

29 30 31 34 35 35 36 38

0

20

40

60

1999 2000 2001 2002 2003 2004 2005 2006

Adults 18–64

Children under 18

Millions uninsured

38 38 3942 43

4743

Data: Analysis of Current Population Survey, March 1995–2007 supplements. Updated data from March 2007 Current Population Survey.

44



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 with workers’ earnings and overall inflation

ACCESS: AFFORDABLE CARE


Families with High Medical and Premium Costs Compared with Income, by Family Income

19

44 42

15

5

16

40

29

23

44 42

21

8

20

50

27

0

20

40

60

Total Poor* Low income* Middle

income*

High

income*

Private

employer

Private

nongroup

Public

2001 2005

Percent of nonelderly population with high out-of-pocketmedical costs and premiums relative to income^

^High out-of-pocket costs defined as having combined out-of-pocket expenses for services and premiums greater than 5 percent for persons in families with incomes less than 200% of poverty, and out-of-pocket expenses greater than 10 percent for persons in families with incomes of 200% of poverty or higher.* Poor refers to household incomes <100% of federal poverty level (FPL); low income to 100–199% FPL; middle income to 200–399% FPL; and high income to 400%+ FPL. Data: P. Cunningham, Center for Studying Health System Change analysis of Medical Expenditure Panel Survey.



Family Income Insurance Coverage

Employer Premiums as Percentage of Median Household Incomefor Under-65 Population, Distribution by State, 2005

57

25

32

59

916

20%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 2005

Premium 18%+of income

Premium15%–17.9% ofincome

Premium12%–14.9% ofincome

Premium <12%of income



Under-65 population by premiumsas share of state median income

16 16

13 13

1820

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 and 2005 Medical Expenditure Panel Survey;State median household incomes, under-65 population—2004–2005 and 2006–2007 Current Population Survey.

33

45

29

6168

56

Total Under 200% of

poverty

200% of poverty or

more

Insured all year Uninsured during year

3441

0

25

50

75

100

2005 2007

Medical Bill Problems or Medical Debt

By Income and Insurance Status, 2007National Average

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 medical bills, had to change way of life to pay bills, or has medical debt being paid off over time.Data: 2005 and 2007 Commonwealth Fund Biennial Health Insurance Survey.


*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: G. Claxton, J. Gabel et al., "Health Benefits in 2007: Premium Increases Fall To An Eight-Year Low, While Offer Rates And Enrollment Remain Stable," Health Affairs, September/October 2007 26(5):1407–1416. Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007, and Commonwealth Fund analysis of National Health Expenditures data.

12.0

18.0

0.8

6.1*7.7*

13.9^

12.9*10.9*

8.2*

5.3*

11.2*

8.5 9.2*

0

5

10

15

20Health insurance premiums

Workers earnings

Overall inflation

Increases in Health Insurance Premiums Compared with Other Indicators, 1988–2007

Percent



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: Heart failure, diabetes, pediatric asthma• Medicare ACS admissions

4. Medicare hospital 30-day readmission rates

5. Medicare costs of care and mortality for heart attacks, hip fractures, or colon cancer

6. Medicare costs of care for chronic diseases: diabetes, heart failure, COPD

7. Health insurance administration as percent of total national health expenditures

8. Physicians using electronic medical records

EFFICIENCY


International Comparison of Spending on Health, 1980–2005

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

0

2

4

6

8

10

12

14

16

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

* PPP=Purchasing Power Parity.Data: OECD Health Data 2007, Version 10/2007.

Average spending on healthper capita ($US PPP*)

Total expenditures on healthas percent of GDP

61

EFFICIENCY


Duplicate Medical Tests, Among Sicker Adults

1820

4

89

10

1516

0

10

20

30

NETH CAN UK NZ AUS GER



EFFICIENCY

2005 2007

United States

Percent reporting that doctor ordered test that had already been done in past two years


Test Results or Medical Records Not Available atTime of Appointment, Among Sicker Adults

2322

9

1214

17 1718

0

10

20

30

NETH GER NZ AUS UK CAN



EFFICIENCY

Percent reporting test results/records not available at time of appointment in past two years

2005 2007

United States


Managed Care Health Plans: Potentially InappropriateImaging Studies for Low Back Pain, by Plan Type

26

22

19

15

35

29

0

10

20

30

40

Private Medicaid


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

25 2526

22 21 22

2004* 2005 2006

Private Medicaid

Annual averagesManaged care plans (2006)

* Denotes baseline year.Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).

EFFICIENCY


Went to Emergency Room for Condition That Could Have Been Treatedby Regular Doctor, Among Sicker Adults

26

21

68 8

11

16

19

0

10

20

30

GER NETH NZ UK AUS CAN



EFFICIENCY

2005 2007

United States

Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available


Ambulatory Care–Sensitive (Potentially Preventable) Hospital Admissions for Select Conditions

178

62

242

156

49

230

U.S.Average

Top 10%states

Bottom 10%states

EFFICIENCY

241

137

299

240

126

293

U.S.Average

Top 10%states

Bottom 10%states

2002/2003̂ 2004

Adjusted rate per 100,000 population

498

258

631

476

246

634

0

100

200

300

400

500

600

700

U.S.Average

Top 10%states

Bottom10% states

Diabetes*Heart failure Pediatric asthma

^ 2002 data for heart failure and diabetes; 2003 data for pediatric asthma. *Combines four diabetes admission measures: uncontrolled, short-term complications, long-term complications, and lower extremity amputations. Data: National average—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; State distribution—State Inpatient Databases; not all states participate in HCUP (AHRQ 2005, 2007a).


Medicare Admissions for Ambulatory Care–Sensitive Conditions,Rates and Associated Costs, by Hospital Referral Regions

771

499

610

887

1043

700

465

558

816

926

0

300

600

900

1200

Nationalmean

10th 25th 75th 90th

2003 2005

13.4

10.0

11.8

14.7

16.3

12.6

9.811.1

13.6

15.2

0

5

10

15

20

Nationalmean

10th 25th 75th 90th

2003 2005

Rate of ACS admissions per 10,000 beneficiaries

Costs of ACS admissions as percent of all discharge costs

Percentiles Percentiles

See report Appendix B for complete list of ambulatory care-sensitive conditions used in the analysis.Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data.

EFFICIENCY


18

16

2021

1516

19 20

14

18

0

10

20

30

2003 2005 10th 25th 75th 90th 10th 25th 75th 90th

Medicare Hospital 30-Day Readmission Rates

Hospital Referral Region Percentiles, 2005

State Percentiles, 2005

Percent of Medicare beneficiaries admitted for one of 31 select conditions who are readmitted within 30 days following discharge*

* See report Appendix B for list of conditions used in the analysis.Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data.

EFFICIENCY

U.S. Mean


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 $40,000

Relative Resource Use**

Quality and Costs of Care for Medicare Patients Hospitalizedfor Heart Attacks, Hip Fractures, or Colon Cancer,

by Hospital Referral Regions, 2004

EFFICIENCY

* 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, J. Sutherland, and D. Radley, Dartmouth Medical School analysis of data from a 20% national sample of Medicare beneficiaries.

Median relative resource use=$27,499

Qu

ali

ty o

f C

are

*(1

-Ye

ar

Su

rviv

al

Ind

ex

, M

ed

ian

=7

0%

)


Quality and Costs of Care for Medicare Patients Hospitalizedfor Heart Attacks, Hip Fractures, or Colon Cancer,

by Hospital Referral Regions

30

2728

30 31 3230

2729

30 3133

0

10

20

30

40

Mean ofhighest

90%

10th 25th Median 75th 90th

2000-2002 2004

1-year mortality rate Annual relative resource use, 2004*

* Risk-adjusted spending on hospital and physician services using standardized national prices.Data: E. Fisher, J. Sutherland, and D. Radley, Dartmouth Medical School analysis of data from a 20% national sample of Medicare beneficiaries.

$28,011

$24,906 $25,929$27,499

$28,831$30,263

Mean ofhighest

90%

10th 25th Median 75th 90th

Deaths per 100 Dollars ($)

70

Percentiles Percentiles

EFFICIENCY


Costs of Care for Medicare Beneficiaries with Multiple Chronic Conditions, by Hospital Referral Regions, 2001 and 2005

Average annual reimbursementRatio of percentile

groups

Average10th

percentile25th

percentile75th

percentile90th

percentile90th to

10th75th to

25th

All 3 conditions

20012005

$31,792

$38,004

$20,960

$25,732

$23,973

$29,936

$37,879

$44,216

$43,973

$53,019

2.10 2.06

1.58

1.48

Diabetes + Heart Failure

20012005

$18,461 $23,056

$12,747

$16,144

$14,355

$18,649

$20,592

$26,035

$27,310

$32,199

2.14

1.99

1.43

1.40

Diabetes + COPD

20012005

$13,188

$15,367

$8,872

$11,317

$10,304

$12,665

$15,246

$17,180

$18,024

$20,062

2.03

1.77

1.48

1.36

Heart Failure + COPD

20012004

$22,415

$27,498

$15,355

$19,787

$17,312

$22,044

$25,023

$31,709

$32,732

$37,450

2.13

1.89

1.45

1.44

COPD=chronic obstructive pulmonary disease.Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data.

EFFICIENCY


Percentage of National Health Expenditures Spent on Insurance Administration, 2005

a 2004 b 1999* Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance.Data: OECD Health Data 2007, Version 10/2007.

Net costs of health insurance administration as percent of national health expenditures

EFFICIENCY

1.92.3

2.83.3

3.94.2 4.3

4.8

5.6

6.97.5

0

2

4

6

8

10

a a ab


Physicians’ Use of Electronic Medical Records

17

28

9892 89

79

42

23

0

25

50

75

100

NETH NZ UK AUS GER CAN


AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.Data: 2001 and 2006 Commonwealth Fund International Health Policy Survey of Physicians.

EFFICIENCY

Percent of primary care physicians using electronic medical records

2001 2006

United States


SECTION 5: EQUITY

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– Effective 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.


Infant Mortality

5.7

9

6.6

4.1

13.6

15.2

13.6

11.9

5.5 5.4 5.34.7

Total Less than high

school

High school

graduate

At least some

college

White Black Hispanic

EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES

Infant deaths per 1,000 live births

14.7

9.0

6.35.7

13.6

6.3

5.55.3

4.7

8.4

0

5

10

15

20 White Black Hispanic Asian/PI AI/AN

By Mother’s Education and Race/Ethnicity, 2004By Race/Ethnicity, 1995–2004


^ Denotes baseline year. PI=Pacific Islander; AI/AN=American Indian or Alaskan Native.Data: National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2007b, Mathews 2007).

Working-Age Adults with Health Limits on Activities or Work, 2006

12.9

9.2 10.3

19.617.0

9.2

15.6

27.328.4

12.8

29.4

48.2

0

25

50

U.S.

Average

Age 18–29 Age 30–49 Age 50–64

$50,000+ $25,000-49,000 <$25,000

Percent of adults limited in any activities because of physical, mental, or emotional problems


17.6

10.6

14.8

27.0

17.0

9.8

18.3

30.1

U.S.

Average

Age 18–29 Age 30–49 Age 50–64

Insured Uninsured

By Family Income By Insurance Status


Data: D. Belloff, Rutgers Center for State Health Policy analysis of Behavioral Risk Factor Surveillance System.

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: Equity indicator was not updated due to lack of data. Baseline figures are presented. *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 (Clegg 2002; Singh 2003).

77



Coronary Heart Disease and Diabetes-Related Mortality,by Race/Ethnicity and Education Level, 2004

160 159

207

127

101

73

30

0

50

100

150

200

250

Total White Black Hispanic Lessthan high

school

Highschool

graduate

At leastsome

college


Coronary Heart Disease Mortality

Age-adjusted per 100,000 population

7668

135

90

62

40

17

0

50

100

150

200

250

Total White Black Hispanic Less thanhigh

school

Highschool

graduate

At leastsome

college

Diabetes-Related Mortality

Note: Data by education level based on total of 36 reporting states and D.C. for people ages 25–64.Data: National Vital Statistics System—Mortality (Retrieved from DATA2010 at http://wonder.cdc.gov/data2010).


http://wonder.cdc.gov/data2010

4245

39

28 30

49

3732

46

30

21

0

20

40

60

3639

22

28

34

46

37

27

Receipt of Recommended Preventive Care for Older Adults,by Race/Ethnicity, Family Income, and Insurance Status, 2005

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. See report Appendix B for complete description.Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.

EQUITY: EFFECTIVE CARE


18

14

4240

10

44

23

19

2831

10

32

0

25

50

27

21

4138

13

46Children ages 6–19 Adults ages 20–64 Adults ages 65–74

Untreated Dental Caries, by Age, Race/Ethnicity,and Income, 2001–2004

Percent of persons with untreated dental caries

80

Data: Race/ethnicity—National Health and Nutrition Examination Survey (NCHS 2007); Total and income—J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.



18

24

13

29

23

16

31

38

0

25

50

27

20

44 44

Children ages 6–19 Adults ages 20–64 Adults ages 65–74

Untreated Dental Caries, by Age and Insurance, 2001–2004

Percent of persons with untreated dental caries

81

Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.



1712

23 26

15 15 14

2219

37

0

25

50

75

100

Adults with Poorly Controlled Chronic Diseases, by Race/Ethnicity, Family Income, and Insurance Status, 1999–2004

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

* High refers to household incomes >400% of federal poverty level (FPL); middle to 200%–399% FPL; near poor to 100%–199% FPL; and poor to <100% FPL.Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey.


64 6366

71

6064

67 69

59

79

0

25

50

75

100


Receipt of All Three Recommended Services for Diabetics,by Race/Ethnicity, Family Income, Insurance, and Residence, 2004

47

48

47

38

42

58

49

47

47

38

39

0 20 40 60 80 100

Rural**

Urban**

Uninsured*

Private*

<100% of poverty



400%+ of poverty

Hispanic

Black

White

Total

Percent of diabetics (ages 40+) who received HbA1c test, retinal exam, and foot exam in past year

*Insurance for people ages 40–64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants. NA=data not available. Data: Medical Expenditure Panel Survey (AHRQ 2007a).


NA


Medical, Medication, and Lab Errors, by Race/Ethnicity,Income, and Insurance Status, 2007

20 2022

1618

24

18

25

0

20

40

Total White Black Hispanic Aboveaverage

Belowaverage

Insured allyear

Uninsuredany time

Race/ethnicity Income Insurance status

Data: 2007 Commonwealth Fund International Health Policy Survey.


EQUITY: SAFE CARE

Percent of adults ages 18–64 reporting medical mistake, medication error, or lab error in past two years

Select AHRQ Patient Safety Indicators, 2004

Risk adjusted rate per 1,000 discharges* Failure to rescue Decubitus ulcers

Selected infections due to medical care

Postoperative pulmonary embolus or deep vein

thrombosisPostoperative

sepsis

RACE/ETHNICITY

White 122.3 24.3 1.7 8.4 10.4

Black 116.8 36.0 1.9 10.7 10.9

Hispanic 130.4 27.2 1.2 8.2 11.3

Asian/Pacific Islander 140.3 22.4 1.4 6.4 12.4

MEDIAN INCOME OF PATIENT ZIPCODELess than $25,000 124.0 29.6 1.6 10.2 14.9

$45,000 or more 119.4 26.5 1.6 9.2 9.8

INSURANCE

Private insurance 112.2 19.0 1.2 7.8 8.7

Uninsured/self pay 135.6 17.6 1.3 7.9 9.2

PATIENT RESIDENCE

Urban 121.5 29.8 1.7 10.0 10.9

Rural 111.3 21.7 1.2 7.6 10.3

* Rates exclude complications present on admission and are adjusted for gender, comorbidities, and diagnosis-related group clusters.Data: Race/ethnicity—HCUP, State Inpatient Database (AHRQ 2007b); income area, insurance, and patient residence—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (AHRQ 2007a).


EQUITY: SAFE CARE

Pressure Sores Among High-Risk and Short-Stay Residentsin Nursing Facilities by Race/Ethnicity, 2005

13

20

17

25

14

24

11

22

13

21

0

20

40

High risk residents Short-stay residents

White Black Hispanic Asian/PI AI/AN


EQUITY: SAFE CARE

Percent of nursing home residents with pressure sores

PI=Pacific Islander; AI/AN=American Indian or Alaskan Native.Data: Nursing Home Minimum Data Set (AHRQ 2007b).

Waiting Time to See Doctor When Sick, by Race/Ethnicity,Income, and Insurance Status, 2007

20

16

36

28

16

26

18

27

0

20

40


Belowaverage

Insured allyear

Uninsuredany time



Percent of adults ages 18–64 who reported waiting six or more days for an appointment when sick or needed medical attention


EQUITY: PATIENT-CENTERED, TIMELY CARE

Doctor–Patient Communication by Race/Ethnicity, Family Income, Insurance, and Residence, 2004

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.Data: Medical Expenditure Panel Survey (AHRQ 2007b).

710

199

168

1412

119

10

0 5 10 15 20

Rural**

Urban**

Uninsured*

Private insurance*

<100% of poverty

400+% of poverty

Asian

Hispanic

Black

White

Total

EQUITY: PATIENT-CENTERED, TIMELY CARE


Duplicate Medical Tests, by Race/Ethnicity, Income, and Insurance Status, 2007

1413 13

15

11

17

11

19

0

10

20

30


Belowaverage

Insured allyear

Uninsuredany time




EQUITY: COORDINATED AND EFFICIENT CARE

Percent reporting that doctor ordered test that had already been done in past two years

Test Results or Medical Record Not Available at Time of Appointment, by Race/Ethnicity, Income, and Insurance Status, 2007

1715

20 20

12

23

14

23

0

10

20

30


Belowaverage

Insured allyear

Uninsuredany time





Percent reporting test results/records not available at time of appointment in past two years

Went to Emergency Room for Condition That Could Have Been Treatedby Regular Doctor, by Race/Ethnicity, Income, and

Insurance Status, 2007

15 15

22

11 11

22

13

20

0

10

20

30


Belowaverage

Insured allyear

Uninsuredany time





Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available

Diabetes**

98

374

144110

390

Heart failure Pediatric asthma

178

667

444

173

554

240

520

392

904

0

500

1000

Adjusted rate per 100,000 population

Ambulatory Care–Sensitive (Potentially Preventable) Hospital Admissions, by Race/Ethnicity and Patient Income Area, 2004/2005*

* 2004 data for diabetes and pediatric asthma; 2005 data for heart failure. ** Combines 4 diabetes admission measures: uncontrolled,short-term complications, long-term complications, and lower extremity amputations. Patient Income Area=median income of patient zip code. NA=data not available.Data: Race/ethnicity—Healthcare Cost and Utilization Project, State Inpatient Databases and National Hospital Discharge Survey (AHRQ 2007b); Income area—HCUP, Nationwide Inpatient Sample (AHRQ 2007a, retrieved from HCUPnet at http://hcupnet.ahrq.gov).

NA

92



http://hcupnet.ahrq.gov/

Nonelderly Adults with Time Uninsured During the Year,by Family Income and Race/Ethnicity, 2004

21

11

22

3743

28

17

26

3833

43

18

42

5451

0

25

50

75

100

Total High income Middle income Near poor Poor

White Black Hispanic

Percent of nonelderly adults (ages <65) who had no health insurance coverage sometime during the year

Note: High refers to household incomes >400% of federal poverty level (FPL); middle to 200-399% FPL; near poor to 100% to 199% FPL; and poor to <100% FPL.Data: Medical Expenditure Panel Survey (AHRQ 2007b).

93

EQUITY: ACCESS


Cost-Related Access Problems, by Race/Ethnicity, Income,and Insurance Status, 2007

72

35

50

26

45

46

45

61

46

0 20 40 60 80 100

Uninsured during year

Insured all year

<200% of poverty


400%+ of poverty

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: 2007 Commonwealth Fund Biennial Health Insurance Survey.


EQUITY: ACCESS

SECTION 6. SYSTEM CAPACITY TO INNOVATE AND IMPROVE

Health Care Workforce• Primary care medical residency positions filled• Hospital employee satisfaction• Nursing home employee satisfaction• Hospital nursing staff vacancy rates (cannot update)• Nursing home staff turnover rates (cannot update)• Nursing home staff hours per patient day

Organizational Culture• Hospital organizational culture• Nursing home resident-centered care practices

Infrastructure• National health expenditures invested in research and public health

activities compared with insurance administration costs

SYSTEM CAPACITY

The Scorecard addresses but does not score indicators for system capacity to innovate and improve.


Primary Care Medical Residency Positions Filled by U.S. Medical School Graduating Seniors and Other Applicants: 1997-2007

3,167

1,9671,648 1,602

837

1,1551,384 1,406

0

1,000

2,000

3,000

4,000

5,000

1997 2002 2006 2007

Positions filled by other applicants*

Positions filled by U.S. medical school graduating seniors

Note: Includes family medicine, family medicine-psychiatry, internal medicine-primary, internal medicine-family medicine, internal medicine-pediatrics, and pediatrics-primary positions. *Other applicants includes U.S. physicians, osteopaths, 5th Pathway, Canadian students, and U.S. and non-U.S. graduates of international medical schools.

Data: American Academy of Family Physicians analysis of National Resident Matching Program Advanced Data Tables, 2007.

4,004

3,122 3,032 3,008

SYSTEM CAPACITY


Data: 2006 Press Ganey Associates, Inc. Data represent the experiences of 121,882 employees across 132 facilities in 2006.

Hospital Employee Satisfaction, 2006

58.361.2

65.8 68.071.4

60.363.1

66.2 68.8 71.5

0

25

50

75

100

10th percentile 25th percentile 50th percentile 75th percentile 90th percentile

Registered Nurses All Employees

97

SYSTEM CAPACITY


Overall Satisfaction Score

Nursing Home Workforce Satisfaction, 2006

3844

5158

64

3744

5259

66

4449

5560

65

0

25

50

75

100

10th percentile 25th percentile 50th percentile 75th percentile 90th percentile

Nursing assistants* Nurses All nursing home employees

Composite satisfaction scores (average of 21 survey items) where 100=excellent and 0=poor

Data: MyInnerView, Inc., 2006 National Survey of Nursing Home Workforce Satisfaction. Scores are national estimates from 106,858 staff in 1,933 nursing facilities in every state (except Alaska) and the District of Columbia. *CNA/NA


SYSTEM CAPACITY

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

99

SYSTEM CAPACITY


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

Highest 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).

100

SYSTEM CAPACITY


Nursing Home Staff Hours Per Patient Day

0.75

1.30

2.80

0.66

1.40

2.98

0.10

0.86

2.00

0.3

1.1

2.3

0

1

2

3

4

Registered Nurses All Licensed Nursing Staff* Nursing Aides

Recommended Threshold# 90th %ile States 10th %ile States US Median

# Staffing thresholds as identified in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Report to Congress: Phase II Final, December 2001. * Licensed staff includes registered and licensed nurses.Note: Staff positions are measured in full-time equivalents, which is based on a 35 hour workweek. Data: American Health Care Association, CMS OSCAR data, 2007.

101

Distribution by Direct Care Staff

SYSTEM CAPACITY


Hospital Organizational Culture: Staff Perceptionsof Teamwork and Learning Environment, 2007

79

70

57

44

96 94 91

8287

8072

56

71

61

44

32

0

25

50

75

100

Teamwork withinunits

Organizationallearning & continuous

improvement

Teamwork acrossunits

Nonpunitive responseto error

Average Best hospital 90th %tile hospitals 10th %tile hospitals

Percent of staff giving positive responses

Data: Hospital Survey on Patient Safety Culture Comparative Database, results for 160,176 staff in 519 participating hospitals submitting data in 2007. Agency for Healthcare Research and Quality.

SYSTEM CAPACITY


Adoption of Culture Change by Nursing Homes, 2007Categories of Nursing Homes, by Extent of Culture Change Adoption

SYSTEM CAPACITY

CULTURE CHANGE ADOPTERS

31%

CULTURE CHANGE STRIVERS

25%

TRADITIONAL43%

Culture change definition* describes nursing home only in a few respects or not at all, and leadership is not very committed to adopting culture change

Culture change definition* completely or for the most part

describes nursing home

Culture change definition* describesnursing home only in a few respectsor not at all, but leadership is extremely or very committed to adopting culture change

* Culture change or a resident-centered approach means an organization that has home and work environments in which: care and all resident-related activities are decided by the resident; living environment is designed to be a home rather than institution; close relationships exist between residents, family members, staff, and community; work is organized to support and allow all staff to respond to residents' needs and desires; management allows collaborative and group decision making; and processes/measures are used for continuous quality improvement.Data: 2007 Commonwealth Fund National Survey of Nursing Homes.


National Health Expenditures Spent on Public Health Activities Compared with Insurance Administration Costs

55

35

78

0

20

40

60

80

100

National health

expenditures

Government public

health activities

Insurance

administrative

costs

43.4

81.8

53.9

129.0

58.7

145.4

0

25

50

75

100

125

150

175

Government public healthactivities

Insurance administrativecosts

2000 2004 2006

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 (Catlin et al. 2008).

Dollars (in billions) Percent growth from 2000 to 2006

104

SYSTEM CAPACITY


References

AHCA (American Health Care Association). 2003. Results of the 2002 AHCA survey of nursing staff vacancy and turnover in Nursing Homes. Washington, D.C.: American Health Care Association.

AHRQ (Agency for Healthcare Research and Quality).

2007a. National Healthcare Quality Report, 2007: Data Tables Appendix. http://www.ahrq.gov/qual/nhqr07/

2007b. National Healthcare Disparities Report, 2007: Appendix D: Data Tables. http://www.ahrq.gov/qual/nhdr07/

2006. National Healthcare Quality Report, 2006. Data Tables Appendix. http://www.ahrq.gov/qual/nhqr06/



2003. National Healthcare Quality Report, 2003.

Allred, N., K. Wooten, and Y. Kong, “The association of health insurance and continuous primary care in the medical home on vaccination coverage for 19- to 35-month-old children,” Pediatrics 119, no 1 (2007):4-11.

Catlin, A., et al., “National health spending in 2006: a year of change for prescription drugs,” Health Affairs 27, no 1 (2008):14-29.

Clegg, L., et al., ”Cancer survival among US whites and minorities: a SEER program population-based study,” Archives of Internal Medicine 162, no 17 (2002):1985-93.

Edwards, J., et al., “National Healthcare Safety Network, data summary for 2006, issued June 2007,” American Journal of Infection Control 35 (2007):290-301.

HRSA (Health Resources and Services Administration). 2005. The National Survey of Children’s Health 2003. Rockville, M.D.: U.S. Department of Health and Human Services.

Mathews, T., and M. MacDorman, “Infant mortality statistics from the 2004 period linked birth/infant death data set,” National Vital Statistics Report 55, no 15 (2007). Hyattsville, Md.: National Center for Health Statistics.

MedPAC (Medicare Payment Advisory Commission). 2007. Quality of care in the Medicare program. A Data Book: Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Committee.

MedPAC (Medicare Payment Advisory Commission). 2005. Quality of care for Medicare beneficiaries. A Data Book: Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Committee.

Nolte, E., and C. M. McKee, “Measuring the health of nations: updating an earlier analysis,” Health Affairs 27, no 1 (2008):58-71.


http://www.ahrq.gov/qual/nhqr07/

http://www.ahrq.gov/qual/nhdr07/




References (continued)

NCHS (National Center for Health Statistics). 2007. Health, United States, 2007. Hyattsville, Md.: Centers for Disease Control and Prevention.

NCQA (National Committee for Quality Assurance). 2007. HEDIS Audit Means, Percentiles and Ratios: 2006. Washington, D.C.: National Committee for Quality Assurance.

Pace, K., et al. 2005. Acute hospitalization of home health patients report of analyses, literature review and technical expert panel. Paper presented at the 2005 National Association for Home Care Annual Meeting, Seattle, Washington and 2005 Tri-Regional QIO Conference, St. Pete Beach, Fla.

SAMHSA (Substance Abuse and Mental Health Services Administration). 2007. Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, Md.

SAMHSA (Substance Abuse and Mental Health Services Administration). 2006. Results from the 2005 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-30, DHHS Publication No. SMA 06-4194). Rockville, Md.

Singh G., et al. 2003. Area socioeconomic variations in US cancer incidence, mortality, stage, treatment, and survival 1975-1999. NCI Cancer Surveillance Monograph Series, Number 4. NIH Publication No. 03-5417. Bethesda, Md.: National Cancer Institute.

WHO (World Health Organization). 2003. The World Health Report 2003: shaping the future. Geneva, Switzerland: World Health Organization.


Documents

National Scorecard, 2008: Chartpack This Chartpack presents data for all indicators scored in the National Scorecard on U.S. Health System Performance,