THE COMMONWEALTH FUND National Scorecard on U.S. Health System Performance: Complete Chartpack Cathy Schoen, Senior Vice President Sabrina K. H. How, Research

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



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



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



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.



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



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


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


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.



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*



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).



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*



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



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)



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


5255

5862

67

47

5457

6165

46

53 5359

61

0

50

100

2000 2001 2002 2003 2004


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).



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*



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.



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


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



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*



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).



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



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



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


Annual averagesManaged care plans (2004)

Data: Health Plan Employer Data and Information Set (NCQA 2005a, 2005b).



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



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



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


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.


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


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


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)


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


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


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


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).


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).


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


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?



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).



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)



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



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.

* *****



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



45

SECTION 3. ACCESS


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


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


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



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



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



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


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



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



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


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



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



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


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


EFFICIENCY

58

6

9 10 11

1820

0

20

40

UK NZ CAN AUS US GER

15

2523

12

21

16

23


Belowaverageincome

Insured Uninsured


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.


EFFICIENCY

59

11 12

16 16

19

23

0

20

40

GER AUS NZ UK CAN US

20

3028

18

27

21

30


Belowaverageincome

Insured Uninsured


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.


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).


EFFICIENCY

61

69

1215

21

26

0

25

50

GER NZ UK AUS CAN US

23

41

24

20

29

23

36


Belowaverageincome

Insured Uninsured


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.


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).

*


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.


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.


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


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 ($)


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.


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 *


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).


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.


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).


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).



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



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

*



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.


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

*



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

* ** *



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



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).

*

**



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).


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


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

*

**


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


7672

66

52

42

33


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


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


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*


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


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.


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.


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



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).



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



90


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

Documents

THE COMMONWEALTH FUND National Scorecard on U.S. Health System Performance: Complete Chartpack Cathy Schoen, Senior Vice President Sabrina K. H. How, Research