Chartpack 2008 PDF

COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM
National Scorecard on U.S. Health System Performance, 2008
Chartpack
ONE EAST 75TH STREET NEW YORK, NY 10021-2692 TEL 212.606.3800 FAX 212.606.3500 www.commonwealthfund.org
JULY 2008
The Commonwealth Fund Commission on a High Performance Health System Membership

James J. Mongan, M.D. Chair of the Commission President and CEO Partners HealthCare System, Inc. Maureen Bisognano Executive Vice President & COO Institute for Healthcare Improvement Christine K. Cassel, M.D. President and CEO American Board of Internal Medicine and ABIM Foundation Michael Chernew, Ph.D. Professor Department of Health Care Policy Harvard Medical School Patricia Gabow, M.D. CEO and Medical Director Denver Health Robert Galvin, M.D. Director, Global Health General Electric Company Fernando A. Guerra, M.D. Director of Health San Antonio Metropolitan Health District Glenn M. Hackbarth, J.D. Chairman MedPAC George C. Halvorson Chairman and CEO Kaiser Foundation Health Plan, Inc. Robert M. Hayes, J.D. President Medicare Rights Center Cleve L. Killingsworth Chairman and CEO Blue Cross Blue Shield of Massachusetts Sheila T. Leatherman Research Professor School of Public Health University of North Carolina Judge Institute University of Cambridge Gregory P. Poulsen Senior Vice President Intermountain Health Care Dallas L. Salisbury President & CEO Employee Benefit Research Institute Sandra Shewry Director California Department of Health Services Glenn D. Steele, Jr., M.D., Ph.D. President and CEO Geisinger Health System Mary K. Wakefield, Ph.D., R.N. Associate Dean School of Medicine Health Sciences Director and Professor Center for Rural Health University of North Dakota Alan R. Weil, J.D. Executive Director National Academy for State Health Policy President Center for Health Policy Development Steve Wetzell Vice President HR Policy Association
Stephen C. Schoenbaum, M.D. Executive Director Executive Vice President for Programs The Commonwealth Fund Anne K. Gauthier Deputy Director Assistant Vice President The Commonwealth Fund Cathy Schoen Research Director Senior Vice President for Research and Evaluation The Commonwealth Fund Rachel Nuzum Senior Policy Director The Commonwealth Fund Allison Frey Program Associate The Commonwealth Fund
The Commonwealth Fund

The Commonwealth Fund, among the first private foundations started by a woman philanthropist Anna M. Harknesswas established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for societys most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries.
This Chartpack presents data for all indicators scored in 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 Commissions 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 72 71 67 58 52 53 70 71 67 65
0
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
Healthy Lives
2006 Revised 2008
Quality
Access
Efficiency
Equity
OVERALL SCORE
100
2
HEALTHY LIVES
SECTION 1. HEALTHY LIVES Scored Indicators: 1. 2. 3. 4. 5. Mortality amenable to health care Infant mortality rate Healthy life expectancy at age 60* Adults under 65 limited in any activities because of health problems 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 3
HEALTHY LIVES
Mortality Amenable to Health Care

Deaths per 100,000 population*
150
1997/98
109
2002/03
130 116 106 115 113
134
128 115
100
76 81
99 88 84 89 89
97 88
97
50
65 71 71 74 74 77 80 82 82
84
84
90
93
96
101
103
103
104
110
0
Ita ly Ca na da No rw Ne ay th er la nd s Sw ed en Gr ee ce Au st ria Ge rm an y Fi nl an Ne d w Ze al an d De Un nm ite ar d k Ki ng do m Ire la nd Po rtu Un ga ite l d St at es Ja pa n Au st ra lia Sp ai n Fr an ce
* 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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 4
HEALTHY LIVES
Infant Mortality Rate

Infant deaths per 1,000 live births
National Average and State Distribution
U.S. average Bottom 10% states Top 10% states
International Comparison, 2004
12
10.3
11.1 10.2 9.9 9.9 9.6 10.1
7.2
7.0
6.9
6.8
7.0
6.8
6.8
6.8 5.3
5.3
5.1
5.0
4.4
4.9 4.8 4.7 4.7
2.8
2.8
3.1
3.2
3.3
0
1998 1999 2000 2001 2002^ 2003 2004
d d n ay en da ark pa lan lan rw na ed nm Ja Ice Ca No Fin Sw De
S. U.
^ Denotes baseline year. Data: National and stateNational Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003, 2004, 2005, 2006, 2007a); international comparisonOECD Health Data 2007, Version 10/2007. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5
HEALTHY LIVES
Healthy Life Expectancy at Age 60, 2002

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 Years
30
W omen
Men
22
20
20 20 20 20 20 19 19 19 19 19 19 19 19 18 18 18 18 18 18 18 17 18 17 17 18 17 16 17 17 16 16 16 16 16 16 16 16 16 16 16 15 15 15 15 14
10
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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 6
HEALTHY LIVES
Data: D. Belloff, Rutgers Center for State Health Policy analysis of Behavioral Risk Factor Surveillance System. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 7 7
S Jap w itz an er la nd Fr an ce S pa S in w ed A en us tr al ia Ita A ly us tr C ia an a B da el gi G um er m an y N or w ay Ic el an Fi d N nl et an he d r N ew lan d Ze s al a nd U ni G te r d ee K ce in U gd ni om te d S ta te P s or tu ga l Ir el C D and ze en ch m R ark ep ub lic
Working-Age Adults with Health Limits on Activities or Work

Percent of adults (ages 1864) limited in any activities because of physical, mental, or emotional problems
National Average and State Distribution By Age Group
40 2004 30 23.4 20 14.9 11.5 10 20.1 17.5 13.2 8.3 10.3 13.4 15.4 24.2 2006 2004 2006 27.4
0
U.S. Average Top 10% States Bottom 10% States
Age 1829
Age 3049
Age 5064
HEALTHY LIVES
School Absences Due to Illness or Injury, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
Percent of children (ages 617) who missed 11 or more school days due to illness or injury during past year
U.S. average
5.2 3.8 8.1 5.5 4.8 4.2 3.6 8.0 4.2 4.7
0 5 10
Top 10% states Bottom 10% states
W hite Black Hispanic
400%+ of poverty <100% of poverty
Private insurance Uninsured
Note: Indicator was not updated due to lack of data. Baseline figures from Scorecard 2006 are presented. Data: 2003 National Survey of Childrens Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 8
QUALITY
SECTION 2. QUALITY Quality includes indicators organized into four groups: 1. 2. 3. 4. Effective 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: EFFECTIVE CARE
Effective Care Scored Indicators: 1. 2. Adults received recommended screening and preventive care Children received recommended immunizations and preventive care Received all recommended doses of five key vaccines Received both medical and dental preventive care visits* Needed mental health care and received treatment Adults Children* Chronic disease under control Adults with diabetes whose HbA1c level <9% Adults with hypertension whose blood pressure <140/90 mmHg Hospitalized patients receive recommended care for heart attack, heart failure, and pneumonia
3.
4.
5.
Receipt of Recommended Screening and Preventive Care for Adults

Percent of adults (ages 18+) who received all recommended screening and preventive care within a specific time frame given their age and sex*
U.S. Average
2002 2005
49 50
U.S. Variation 2005

400%+ of poverty 200%399% of poverty <200% of poverty Insured all year Uninsured part year Uninsured all year 0 20
58 47 39 53 46 32
40 60 80 100
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 11
Immunizations for Young Children

Percent of children (ages 1935 months) who received all recommended doses of five key vaccines*
U.S. average Top 10% states Bottom 10% states
White
By Family Income, Insurance Status**, and Race/Ethnicity, 2006

82 77 80 77 82 83 75 71
0 25 50 75 100
100
82 80 74 84 75 89 79 88 81 88 81 86 81
Black Hispanic
75
73
71 66 66 65
72
71
72
<100% of poverty 100%+ of poverty Insured all year
50
25
Insured part year Uninsured all year
0
2000 2001 2002 2003^ 2004 2005 2006
^ Denotes baseline year. * Recommended vaccines include: 4 doses of diphtheria-tetanus-pertussis (DTP), 3+ doses of polio, 1+ dose of measles-mumpsrubella, 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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 12
Preventive Care Visits for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
Percent of children (ages <18) who received BOTH a medical and dental preventive care visit in past year
U.S. average
59 73 48 62 58
49
70
48
Private insurance Uninsured 0 20
63 35
40 60 80 100
Note: Indicator was not updated due to lack of data. Baseline figures from 2006 Scorecard are presented. Data: 2003 National Survey of Childrens Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 13
Adults with Major Depressive Episode Who Received Treatment

Percent of adults (ages 18+) with major depressive episode who received treatment in the past year*
U.S. Average
2004 2006
65 69
U.S. Variation 2006
White Black Hispanic Private Medicaid Medicare** Uninsured 0 20 40
73 60 52 71 80 87 50
60 80 100
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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 14
Mental Health Care for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
Percent of children (ages <18) who needed and received mental health care in past year*
U.S. average
59 74 47 65 52
42
64
53
63 34
40 60 80 100
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 Childrens Health (HRSA 2005; Retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 15
Chronic Disease Under Control: Diabetes and Hypertension

National Average By Insurance, 1999-2004
Percent of adults (age 18+)

100
1999-2000
2003-2004
Insured 81 Uninsured
88 79
75
63
50
41 31
41
25
21
0
Diabetes under control* High blood pressure under control**
Diabetes under control*
High blood pressure under control**
*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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 16
Chronic Disease Under Control: Managed Care Plan Distribution, 2006

Diabetes
Percent of adults with diagnosed diabetes whose HbA1c level <9.0%
100
Mean 90th % ile 10th % ile
Hypertension
Percent of adults with hypertension whose blood pressure <140/90 mmHg
100
Mean
90th % ile
10th % ile
88 81
75
70
73
68 56
49
75 60 50
68
57
67 49
53
60
50
66
46 39
30
25
25
0 Private Medicare Medicaid Private Medicare Medicaid
Note: Diabetes includes ages 1875; hypertension includes ages 1885. Data: Healthcare Effectiveness Data and Information Set (NCQA 2007). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 17
Hospitals: Quality of Care for Heart Attack, Heart Failure, and Pneumonia
Overall Composite for All Three Conditions 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*
Median 90th % ile 10th % ile
2004
100 84 75 99 100 90 91 96
2006
96
78
99 88 91
98 87 71
95 76
75
50
25
0
Median Best 90th %ile 10th %ile
Heart Attack Heart Failure 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 18
Hospital Quality of Care for Heart Attack, Heart Failure, and Pneumonia: Overall Composite Using Expanded Set of 19 Clinical Indicators*, 2006
Percent of patients who received recommended care for all three conditions
100
100 87
94 74
91
89 82
75
50
25
0
Median Best 90th % ile 10th %ile Best 90th % ile 10th % ile
Hospitals
States
*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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 19
Hospital Quality of Care by Condition: Composites for Heart Attack, Heart Failure, and Pneumonia
HOSPITALS
Percent of patients who received recommended care: Median Best 90th percentile 10th percentile Best
STATES
90th percentile 10th percentile
Acute myocardial infarction

(Original: 5 indicators)
2004 2006
(Expanded: 8 indicators*)
92 96 95
100 100 100
98 99 98
80 88 87
97 98 98
96 97 97
89 93 92
2006
Heart failure
2004 2006
83 91 83
100 100 100
94 98 95
62 71 61
91 94 90
89 93 87
79 81 75
2006
Pneumonia
2004 2006
78 87 87
99 100 100
88 95 94
66 76 77
82 92 91
79 91 90
69 83 83
2006
*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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 20 20
QUALITY: COORDINATED CARE
Coordinated Care
Scored Indicators:
1. 2. 3. Adults under 65 with an accessible primary care provider Children with a medical home* 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 Nursing homes: hospital admissions and readmissions Home health: hospital admissions
4. 5.
10
Adults with an Accessible Primary Care Provider

Percent of adults ages 1964 with an accessible primary care provider*
U.S. Average
2002 2005
66 65
U.S. Variation 2005

W hite Black Hispanic 400%+ of poverty 200%399% of poverty <200% of poverty Insured all year Uninsured part year Uninsured all year 0 20
69 59 49 73 63 53 74 51 37
40 60 80 100
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 22
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*
U.S. average
46 60 36 53 39
30
58
31
53 23
40 60 80 100
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 enough time and communicated clearly, provided telephone advice or urgent care and followed up after the childs specialty care visits. Data: 2003 National Survey of Childrens Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 23
11
Medications Reviewed When Discharged from the Hospital, Among Sicker Adults, 2005
Percent of hospitalized patients with new prescription who reported prior medications were reviewed at discharge
100
86 77
75
73
72
69
67
50
25
GER
AUS
UK
CAN
NZ
US
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 24
Heart Failure Patients Given Complete Written Instructions When Discharged, by Hospitals and States
Percent of heart failure patients discharged home with written instructions*
100
94 87
2004
2006 80
75
68 50 36 49
69 61 56
50
33
25
9
0
U.S. m ean 90th % ile 10th % ile Median 90th %ile 10th % ile
Hospitals
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 25
12
Managed Care Health Plans: 30-Day Follow-Up After Hospitalization for Mental Illness
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
M ean 90th %ile 10th %ile
100
Private
M edicare
M edicaid
88
75 76 63 56 50
81
80
71 59 55
73 61
74 61 56
74 60 56
76 61
76 59 57
76
58
56 58
52
55
29 25 17
0 Private Medicare Medicaid

2000 2001 2002 2003 2004* 2005 2006
Managed Care Plans (2006) * Denotes baseline year. Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).
Annual averages
26
Nursing Homes: Hospital Admission and Readmission Rates Among Nursing Home Residents
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
40
40
2000
2004
27
2000
26
2004
20
17
19 12 13 14
21
23
20
11
17
18 13 15
19 15 16
20
22 22
0
Median 10th %ile 25th %ile 75th %ile 90th %ile
0
Median 10th %ile 25th %ile 75th %ile 90th %ile
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 27
13
Home Health Care: Hospital Admissions

Percent of home health care patients who had to be admitted to the hospital
60
2003-2004^
2006-2007
48 37
47
40
28 28 17 19 20 20
35
20
0
Mean Top 25% Bottom 25% Top 10% Bottom 10%
Home Health Agencies
States
^ 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) Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 28
QUALITY: SAFE CARE
Safe Care Scored Indicators: 1. 2. Patients reported medical, medication, or lab test error 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 Nursing home residents with pressure sores Hospital-standardized mortality ratios Surgical infection prevention Adverse events and complications of care in hospitals
3. 4. 1. 2.
Other Indicators:
29
14
QUALITY: SAFE CARE
EXHIBIT 16
Medical, Medication, and Lab Errors, Among Sicker Adults
Percent reporting medical mistake, medication error, or lab error in past two years
40 34 30 21 22 32 26 19 28
2005
2007
30
20
10
United States
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 30
QUALITY: SAFE CARE
Ambulatory Care Visits for Treating Adverse Drug Effects

Visits per 1,000 population per year
By Gender, Race, and Region, 2004 Annual Averages, by Care Setting
Total Physician Office Hospital Emergency Department Visits
30
28
22
20
20 18
21 17 17
22
Hospital Outpatient Department Visits 17.4
19.8
16
12.9 11.3
15.3 11.3
10
O th er N or th ea st M id w es t
0
M al e Fe m al e B la ck W hi te To ta l
So ut h
* Denotes baseline year. Data: C. Zhan, AHRQ analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 31
W es t
1999
2000
2001*
2002
2003
2004
15
QUALITY: SAFE CARE
Potentially Inappropriate Antibiotic Prescribing for Children with Sore Throat

Percent of children prescribed antibiotics for throat infection without receiving a strep test*
National Average Managed Care Plan Distribution, 2006
100
Mean
10th % ile
90th % ile
75
74
50
43 35
27
43
44
25
23 14
1997-2003
2004
Private
Medicaid
Note: National average includes ages 317 and plan distribution includes ages 218. * A strep test means a rapid antigen test or throat culture for group A streptococcus. Data: National averageJ. Linder, Brigham and Women's Hospital analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey; Plan distributionHealthcare Effectiveness Data and Information Set (NCQA 2007). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 32 32
QUALITY: SAFE CARE
Inappropriate Use of Medications by Elderly

Percent of community-dwelling elderly adults (ages 65+) who reported taking at least 1 of 33 drugs that are potentially inappropriate for the elderly
National Average By Gender, Race/Ethnicity, and Region, 2004
30
20
19
19
18
19 17
20 17 13 17 14 13 17
20
15
10
0 2000 2001 2002* 2003 2004

B la ck H is pa ni c N or th ea st M id w es t S ou th Fe m al e W hi te M al e W es t
* Denotes baseline year. Data: Medical Expenditure Panel Survey (AHRQ 2007a).
33
16
QUALITY: SAFE CARE
Pressure Sores Among High-Risk and Short-Stay Residents in Nursing Facilities

Percent of nursing home residents with pressure sores
High-Risk Residents Short-Stay Residents
30
2004
2006
2004
2006
24
23
20
13
18
19
17
17 14 12
13 8
10
0
U.S. average Top 10% states Bottom 10% states
U.S. average
Top 10% states
Bottom 10% states
Data: Nursing Home Minimum Data Set (AHRQ 2005, 2007a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 34
QUALITY: SAFE CARE
Hospital-Standardized Mortality Ratios

Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors.* Medicare national average for 2000=100 Ratio of actual to expected deaths in each decile (x 100)
140 120 100 80 60 40 20 0

mean
2000-2002
101 82 85 74 100 79 81
2004-2006
103 83 106 83 106 85 112 86 118
93 78
94 78
97
89
U.S.
10
Decile of hospitals ranked by actual to expected deaths ratios
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 35
17
QUALITY: SAFE CARE
Surgical Infection Prevention, 2006

Percent of surgical patients who received appropriate timing of antibiotics to prevent infections*
100
100 92 80 90 87 73 60
75
50
25
0
Median Best 90th % ile 10th %ile Best 90th % ile 10th % ile
Hospitals
States
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 36
QUALITY: SAFE CARE
Nosocomial Infections in Intensive Care Unit Patients, 2006

Central line-associated bloodstream infection rate, per 1,000 days use
Type of ICU Medical Medical-surgicalmajor teaching Medical-surgicalall others Surgical NeonatalLevel III (infants weighing 750 grams or less) No. of units 73 63 102 72 10% 0.0 0.0 0.0 0.0 25% 0.0 0.6 0.0 0.9
Percentile 50% 2.2 1.9 1.0 2.0 75% 4.2 3.1 2.3 4.4 90% 6.2 5.5 4.5 7.4
42
0.0
2.5
5.2 Percentile
11.0
15.6
Ventilator-associated pneumonia rate, per 1,000 days use

Type of ICU Medical Medical-surgicalmajor teaching Medical-surgicalall others Surgical Neonatal (NICU) (infants weighing 750 grams or less) No. of units 64 58 99 61 36 10% 0.0 0.0 0.0 0.0 0.0 25% 0.9 1.3 0.0 1.8 0.0
50% 2.8 2.5 1.6 4.1 1.7
75% 4.6 5.1 3.8 6.4 4.1
90% 7.2 7.3 6.2 10.0 9.5
Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 37 37
18
QUALITY: SAFE CARE
Potentially Preventable Adverse Events and Complications of Care in Hospitals, National and Medicare Trends
Risk-adjusted rate per 10,000 discharges* Decubitus ulcer (pressure sore) National Medicare Postoperative pulmonary embolism or deep vein thrombosis National Medicare Postoperative sepsis National Medicare Postoperative respiratory failure National Medicare Accidental puncture or laceration National Medicare Infection due to medical care National Medicare 12 20 14 20 15 24 16 25 16 25 NA 15 38 31 44 32 47 36 47 34 48 34 NA 35 63 25 72 34 80 46 86 50 82 53 NA 59 63 80 81 97 92 111 92 120 105 131 NA 121 58 62 66 71 79 86 86 92 89 98 NA 100 1997/1998** 195 206 2000 221 225 2002 236 251 2003 248 267 2004 261 276 2005 NA 282
* 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 figuresHealthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at http://hcupnet.ahrq.gov); Medicare figuresMedPAC analysis of Medicare administrative data using AHRQ indicators and methods (MedPAC 2005, Chart 3-3 and 2007, Chart 4-2). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 38 38
QUALITY: SAFE CARE
Potentially Preventable Adverse Events and Complications of Care in Hospitals Among Medicare Beneficiaries, 20042005
Percent
15 US Average Top 10% States Bottom 10% States
10
9.8 8.8
10.6
6.0 5 2.4 1.9 3.6 4.6 3.6
0 Postoperative complications composite* Adverse drug events composite** Pressure sores
*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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 39 39
19
QUALITY: PATIENT-CENTERED, TIMELY CARE
Patient-Centered, Timely Care Scored Indicators: 1. 2. 3. 4. 5. Ability to see doctor on same/next day when sick or need medical attention Very/somewhat easy to get care after hours without going to the emergency room Doctorpatient communication: always listened, explained, showed respect, spent enough time Adults with chronic conditions given self-management plan* Patient-centered hospital care
Other Indicator: 1. Physical restraints in nursing homes
EXHIBIT 16
Waiting Time to See Doctor When Sick or Need Medical Attention, Among Sicker Adults
Percent of adults who could get an appointment on the same or next day
100
2005
74
2007
75
69
63
58
57
50
47
46 32
25
United States
NZ
NETH
GER
AUS
UK
CAN
20
Difficulty Getting Care on Nights, Weekends, Holidays Without Going to the Emergency Room, Among Sicker Adults
Percent of adults who sought care reporting very or somewhat difficult
100 73 61 50 48 49 50 61
2005
2007
75
68
69
25
United States
NETH
NZ
GER
UK
AUS
CAN
DoctorPatient 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
National Average
100
Managed Care Plan Distribution, 2006

Mean 90th % ile 10th % ile
75
70
75 65 70
74 63 67
73 59
54
50
57
57
25
0 2002* 2003 2004
Private
Medicare**
Medicaid
* Denotes baseline year. **2005 data due to delays in the Medicare CAHPS survey. Data: National averageMedical Expenditure Panel Survey (AHRQ 2005, 2006, 2007a); Plan distributionCAHPS (data provided by NCQA). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 43 43
21
Adults with Chronic Conditions: Receipt of Self-Management Plan, Among Sicker Adults, 2005
Percent of adults with chronic conditions* whose doctor gave plan to manage care at home
100
75
65 58 56 50
50
45 37
25
CAN
US
NZ
AUS
UK
GER
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 44
Patient-Centered Hospital Care: Staff Managed Pain, Responded When Needed Help, and Explained Medicines, by Hospitals, 2007
Percent of patients reporting always
Mean 100 97 75 67
60
Best hospital
90th %ile hospitals 91 72 60

48
10th %ile hospitals 96
75
66 58
49
50
25
0
Staff managed pain well * Staff responded when needed Staff explained m edicines and help ** side effects***
* Patients 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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 45 45
22
Physical Restraints in Nursing Facilities

Percent of nursing home residents who were physically restrained
U.S. average Bottom 10% states Top 10% states
By Race/Ethnicity
20
18.4 14.7
2003
2005
15
9.7
14.1
13.2 11.7
10.7 10.2 9.8 7.6 7.7
10
8.0
7.4
6.8
7.8
8.7 6.6 6.9 5.8
5.9
5
3.7 2.6 2.4 2.2
0 2002 2003 2004
1.9
2005
2006
W hite
Black
Hispanic Asian/PI
AI/AN
PI=Pacific Islander; AI/AN=American Indian or Alaskan Native. Data: Nursing Home Minimum Data Set (AHRQ 2004, 2005, 2006, 2007a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 46
ACCESS
SECTION 3. ACCESS Access includes indicators organized into two groups: 1. 2. Participation Affordability
The Scorecard scores each group of indicators separately, and then averages the two scores to create the overall score for Access.
47
23
ACCESS: PARTICIPATION
Participation Scored Indicators: 1. 2. Adults under 65 insured all year, not underinsured Adults with no access problem due to costs
Other Indicator: 1. Uninsured under 65: national and state trends
48
Uninsured and Underinsured Adults, 2007 Compared with 2003

Percent of adults (ages 1964) who are uninsured or underinsured
100 Underinsured* 75 Uninsured during year
68
19
72
24
50
35
25
42
14 49 28 48
9 26
27 17
4 13
2003 2007 2003
11 16
2007
0 2003 2007
Total Under 200% of poverty 200% of poverty or more
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 49
24
EXHIBIT 16
Access Problems Because of Costs

Percent of adults who had any of three access problems* in past year because of costs
50 40
2005
37
2007
25
25 21 12 5 8
26
United States
NETH
UK
CAN
GER
NZ
AUS
* Did not get medical care because of cost of doctors 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 50
Access Problems Because of Costs, By Income, 2007

Percent of adults who had any of three access problems* in past year because of costs
75
Below average income
Above average income
52
50 37
32
25 5 0 NETH UK CA N GER NZ A US US 8 12 21 25 26
30 22 21
24 18 6 3 9 8 7 18
25
NETH UK
CAN GER AUS
NZ
US
* Did not get medical care because of cost of doctors 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 51 51
25
Percent of Adults Ages 1864 Uninsured by State 19992000

WA MT OR ID WY NE NV UT CA CO KS MO IA IL IN SD ND MN WI MI PA OH WV KY TN AZ NM OK AR MS TX LA FL AK AK AL GA NC SC AZ NM VA NJ NY RI CT MA OR ID WY NE NV UT CA CO KS MO IA IL IN SD VT NH ME WA MT ND MN WI MI PA OH WV KY TN OK AR MS TX LA FL AL GA NC SC VA NJ NY RI CT MA
20052006
VT NH ME
DE MD DC
DE MD DC
HI
23% or more 19%22.9% 14%18.9% Less than 14%
HI
Data: Two-year averages 19992000, updated with 2007 Current Population Survey correction, and 20052006 from the Census Bureaus March 2000, 2001 and 2006, 2007 CPS. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 52
Percent of Children Ages 017 Uninsured by State 19992000

WA MT OR ID WY NE NV UT CA CO KS MO IA IL IN SD ND MN WI MI PA OH WV KY TN AZ NM OK AR MS TX LA FL AK AK AL GA NC SC AZ NM VA NJ NY RI CT MA OR ID WY NE NV UT CA CO KS MO IA IL IN SD VT NH ME WA MT ND MN WI MI PA OH WV KY TN OK AR MS TX LA FL AL GA NC SC VA NJ NY RI CT MA
20052006
VT NH ME
DE MD DC
DE MD DC
HI
16% or more 10%15.9% 7%9.9% Less than 7%

HI
Data: Two-year averages 19992000, updated with 2007 Current Population Survey correction, and 20052006 from the Census Bureaus March 2000, 2001 and 2006, 2007 CPS. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 53
26
Population Under Age 65 Without Health Insurance

Percent uninsured
30 2000 2006
Millions uninsured
60
Adults 1864 Children under 18

43 43 44 47
20 16
20 18 17 12 12
40
38
38
39
42
29
10
20
30
31
34
35
35
36
38
0
A ll under 65 Children under 18 A dults 1864
0
1999 2000 2001 2002 2003 2004 2005 2006
Data: Analysis of Current Population Survey, March 19952007 supplements. Updated data from March 2007 Current Population Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 54
ACCESS: AFFORDABLE CARE
Affordable Care Scored Indicators: 1. 2. Families spending less than 10% of income or less than 5% of income, if low-income, on out-of-pocket medical costs and premiums Population under 65 living in states where premiums for employer-sponsored health coverage are less than 15% of under-65 median household income Adults under 65 with no medical bill problems or medical debt
3.
Other Indicator: 1. Health insurance premium trends compared with workers earnings and overall inflation
55
27
Families with High Medical and Premium Costs Compared with Income, by Family Income
Percent of nonelderly population with high out-of-pocket medical costs and premiums relative to income^
60 44 44 40 23 42 42
2001
2005 40
50
29 20 19 21 15 5 0
Total Poor* Low incom e* M iddle incom e*
27
16 8
20
High income*
Private em ployer
Private nongroup
Public
Family Income
Insurance Coverage
^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 100199% FPL; middle income to 200399% FPL; and high income to 400%+ FPL. Data: P. Cunningham, Center for Studying Health System Change analysis of Medical Expenditure Panel Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 56
Employer Premiums as Percentage of Median Household Income for Under-65 Population, Distribution by State, 2005
Premiums for private coverage as percent of median income per state
30 Median 10th %ile states 90th %ile states
Under-65 population by premiums as share of state median income

100% 90% 80%
16
Premium 18% + of incom e
18 16
15
20 16
70% 60%
32 Premium 15% 17.9% of incom e Premium 12% 14.9% of incom e Premium <12% of incom e
13
13
50% 40% 30% 20% 10%
59
57
25 2
0%
Single household
Families
2003
2005
Data: State averages private premium rates2003 and 2005 Medical Expenditure Panel Survey; State median household incomes, under-65 population20042005 and 20062007 Current Population Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 57
28
Medical Bill Problems or Medical Debt

Percent of adults (ages 1964) with any medical bill problem or outstanding debt*
National Average By Income and Insurance Status, 2007
Insured all year Uninsured during year
100
75
68 61 56 45 33 29
50
41 34
25
2005
2007
Total
Under 200% of poverty
200% of poverty or more
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 58
Percent
20
Increases in Health Insurance Premiums Compared with Other Indicators, 19882007

Health insurance prem iums Workers earnings
18.0 15 12.0 10 8.5
Overall inflation
13.9^ 12.9* 11.2* 10.9* 8.2* 5.3* 9.2* 7.7* 6.1*
5 0.8
*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):14071416. Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007, and Commonwealth Fund analysis of National Health Expenditures data.
19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07
59
29
EFFICIENCY
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 ER use for condition that could have been treated by regular doctor Hospital admissions for ambulatory caresensitive (ACS) conditions National ACS admissions: Heart failure, diabetes, pediatric asthma Medicare ACS admissions Medicare hospital 30-day readmission rates Medicare costs of care and mortality for heart attacks, hip fractures, or colon cancer Medicare costs of care for chronic diseases: diabetes, heart failure, COPD Health insurance administration as percent of total national health expenditures Physicians using electronic medical records
60
2. 3.
4. 5. 6. 7. 8.
EFFICIENCY
International Comparison of Spending on Health, 19802005

Average spending on health per capita ($US PPP*)
$7,000 United States Germany Canada France Australia United Kingdom
16 14 12 10
Total expenditures on health as percent of GDP
$6,000
$5,000
$4,000
8
$3,000
6
$2,000
4 2 0
$1,000
United States Germany Canada France Australia United Kingdom
$-
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
* PPP=Purchasing Power Parity. Data: OECD Health Data 2007, Version 10/2007. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 61 61
19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04
30
EFFICIENCY
Duplicate Medical Tests, Among Sicker Adults

Percent reporting that doctor ordered test that had already been done in past two years
30
2005
2007
20
20 18 15 9 10 16
10 4 0
United States
NETH
CAN
UK
NZ
AUS
GER
EFFICIENCY
Test Results or Medical Records Not Available at Time of Appointment, Among Sicker Adults
Percent reporting test results/records not available at time of appointment in past two years
30 23 20 14 12 10 9
2005
22
2007
17
17
18
United States
NETH
GER
NZ
AUS
UK
CAN
31
EFFICIENCY
Managed Care Health Plans: Potentially Inappropriate Imaging Studies for Low Back Pain, by Plan Type
Percent of health plan members (ages 1850) who received an imaging study within 28 days following an episode of acute low back pain with no risk factors
M ean 10th %ile 90th %ile
40 35 30 29 26 22 20
25
Private
M edicaid
25
26
19 15
22
21
22
10
0 Private Medicaid
2004* 2005 2006
Managed care plans (2006) * Denotes baseline year. Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).
Annual averages
64
EFFICIENCY
Went to Emergency Room for Condition That Could Have Been Treated by Regular Doctor, Among Sicker Adults
Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available
30 26 21 20 16 11 10 6 8 8 19
2005
2007
United States
GER
NETH
NZ
UK
AUS
CAN
32
EFFICIENCY
Ambulatory CareSensitive (Potentially Preventable) Hospital Admissions for Select Conditions

Adjusted rate per 100,000 population
700 600 500 400 300 200 100 0
631 634 498
2002/2003^
2004
476
258 246
299 293 241 240 137 126

178 156 62 49 242 230
U.S. Average
Top 10% states
Bottom 10% states
U.S. Average
Top 10% states
Bottom 10% states
U.S. Average
Top 10% states
Bottom 10% states
Heart failure
Diabetes*
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 averageHealthcare Cost and Utilization Project, Nationwide Inpatient Sample; State distributionState Inpatient Databases; not all states participate in HCUP (AHRQ 2005, 2007a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 66
EFFICIENCY
Medicare Admissions for Ambulatory CareSensitive Conditions, Rates and Associated Costs, by Hospital Referral Regions
Rate of ACS admissions per 10,000 beneficiaries
1200
Costs of ACS admissions as percent of all discharge costs

20
2003
2005
1043
2003
2005
16.3
900
887 771 700 610 558 816
926
15 13.4 12.6 10.0 9.8 11.8
14.7 13.6 11.1
15.2
600
499 465
10
300
0 National mean 10th 25th 75th 90th
Percentiles
National mean
10th
25th
75th
90th
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 67
33
EFFICIENCY
Medicare Hospital 30-Day Readmission Rates

Percent of Medicare beneficiaries admitted for one of 31 select conditions who are readmitted within 30 days following discharge* 30
20
18
18 14 16
20
21 19 15 16
20
10
0
2003 2005 10th 25th 75th 90th 10th 25th 75th 90th
U.S. Mean
Hospital Referral Region Percentiles, 2005
State Percentiles, 2005
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 68
EFFICIENCY
Quality and Costs of Care for Medicare Patients Hospitalized for Heart Attacks, Hip Fractures, or Colon Cancer, by Hospital Referral Regions, 2004
1.20
Quality of Care* (1-Year Survival Index, Median=70%)
Median relative resource use=$27,499

1.10
1.00
0.90
0.80 $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 Relative Res ource Us e**
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 69
34
EFFICIENCY
Quality and Costs of Care for Medicare Patients Hospitalized for Heart Attacks, Hip Fractures, or Colon Cancer, by Hospital Referral Regions
1-year mortality rate
Deaths per 100
Annual relative resource use, 2004*

Dollars ($)
40 30 30 30 27 27
2000-2002 28 29 30 30
2004 31 31 32 33
$28,011 $24,906 $25,929 $27,499 $28,831 $30,263
20
10
0 Mean of highest 90% 10th 25th Median 75th 90th

Mean of highest 90% 10th 25th Median 75th 90th
Percentiles
Percentiles
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 70 70
EFFICIENCY
Costs of Care for Medicare Beneficiaries with Multiple Chronic Conditions, by Hospital Referral Regions, 2001 and 2005
Average annual reimbursement 10th percentile 25th percentile 75th percentile 90th percentile Ratio of percentile groups 90th to 10th 75th to 25th
Average All 3 conditions 2001 2005 Diabetes + Heart Failure 2001 2005 Diabetes + COPD 2001 2005 Heart Failure + COPD 2001 2004 $22,415 $27,498 $13,188 $15,367 $18,461 $23,056 $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
$12,747 $16,144
$14,355 $18,649
$20,592 $26,035
$27,310 $32,199
2.14 1.99
1.43 1.40
$8,872 $11,317
$10,304 $12,665
$15,246 $17,180
$18,024 $20,062
2.03 1.77
1.48 1.36
$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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 71
35
EFFICIENCY
Percentage of National Health Expenditures Spent on Insurance Administration, 2005

Net costs of health insurance administration as percent of national health expenditures
10 8 6 4 2 0
d an nl i F
1.9 2.3 2.8 3.3 3.9 4.2 4.3 4.8 5.6 7.5
6.9
n pa Ja
m lia do ra ng st i u K A d ite Un
ria st Au
s y nd da nd an la na m rla er r a z e e C it G th Sw Ne
* es ce at an St Fr d ite Un
2004 b1999 * 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.
a
72
EFFICIENCY
Physicians Use of Electronic Medical Records

Percent of primary care physicians using electronic medical records
100 98
2001
92 89 79
2006
75
50 28 25 17
42 23
United States
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 73
36
EQUITY
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 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.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 74
EQUITY: LONG, HEALTHY & PRODUCTIVE LIVES
Infant Mortality
Infant deaths per 1,000 live births
By Race/Ethnicity, 19952004
20
By Mothers Education and Race/Ethnicity, 2004

White
Black
Hispanic
A sian/PI
A I/A N
15
14.7 13.6
13.6
15.2 13.6 11.9
10
9.0 6.3
8.4 5.7 5.5 4.7

5.7
9 6.6 5.5 5.4 5.3 4.1 4.7
5.3
0
20 01 20 02 ^ 19 95 19 96 19 97 19 98 19 99 20 00 20 03 20 04
Total Less than high school High school graduate At least som e college
^ 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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 75
37
Working-Age Adults with Health Limits on Activities or Work, 2006

Percent of adults limited in any activities because of physical, mental, or emotional problems
By Family Income By Insurance Status
$50,000+ 50
$25,000-49,000
<$25,000 48.2
Insured
Uninsured
28.4 25 17.0 12.9
29.4
27.3 19.6
18.3 14.8 10.6 9.8
30.1 27.0
12.8 10.3 9.2 9.2
15.6
17.6 17.0
0
U.S. Average Age 1829 Age 3049 Age 5064
U.S. Average Age 1829 Age 3049 Age 5064
Data: D. Belloff, Rutgers Center for State Health Policy analysis of Behavioral Risk Factor Surveillance System. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 76
Five-Year Survival Rates for All Cancers, by Gender, Race/Ethnicity, and Census Tract Poverty Rate
White TOTAL (19881997) Men Women MEN (19881994) Low poverty, <10%* High poverty, 20%+* WOMEN (19881994) Low poverty, <10%* High poverty, 20%+* 63 55 61 52 55 58
Black
Hispanic
Asian
AI/AN
46 47
53 57
50 61
40 47
58 45
60 54
55 44
38 42
58 48
65 60
66 56
44 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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 77 77
38
Coronary Heart Disease and Diabetes-Related Mortality, by Race/Ethnicity and Education Level, 2004
Age-adjusted per 100,000 population
Coronary Heart Disease Mortality Diabetes-Related Mortality
250 207 200 160 150 159 127 101 73 50 30
250
200
150
135 90 76 68 62 40 17
100
100
50
Total
White
Black
Hispanic
At least High Less some than high school school graduate college
Total
White
Black
Hispanic Less than High high school school graduate
At least some college
Note: Data by education level based on total of 36 reporting states and D.C. for people ages 2564. Data: National Vital Statistics SystemMortality (Retrieved from DATA2010 at http://wonder.cdc.gov/data2010). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 78
EQUITY: EFFECTIVE CARE
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 and preventive care within a specific time frame given their age and sex*
60
Adults ages 5064
Adults ages 65+
42
40
45 39 28 30
49 37 32
46
36 39 34 28
46 37 27
30 21
22
20
0
tal To te hi W
k ic ac an Bl sp Hi
ty r ar rty ver rty ar r ea ye ve ye ve o he ty ar po Ot f po of p all all p f d d o o d e e % r r e + 9 % r u s su 0% -39 00 su in In in 40 <2 0% Un Un 20
l ta To
te hi W
k ac Bl
ic an sp Hi
rty ty ty r er er ve he ov ov po Ot fp fp of o o % + % 99 00 0% -3 <2 40 0% 20
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 79
39
Untreated Dental Caries, by Age, Race/Ethnicity, and Income, 20012004

Percent of persons with untreated dental caries Children ages 619
50
Adults ages 2064

46 41
Adults ages 6574

42 44 40
38
28 25 23 19
31
32
27 21
18
13
10
14 10
ty rty n l k er te ve ta ac xica pov hi po To W Bl e M of of + % 0% 100 < 40
ty rty l n k er te ta ve ac xica pov hi To po W Bl e M of of + % 0% 100 < 40
ty ty l n k er er te ta ac xica pov hi ov To Bl W e fp M of o + % 0% 100 40 <
Data: Race/ethnicityNational Health and Nutrition Examination Survey (NCHS 2007); Total and incomeJ. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 80 80
Untreated Dental Caries, by Age and Insurance, 20012004

Percent of persons with untreated dental caries Children ages 619
50
Adults ages 2064

44 44
Adults ages 6574
38 31
27
25 23 16
13 24
29
20
18
l ta To
ly ed ate On ur riv lic ins yP b n Un A Pu
l ta To
ly te ed On iva ur Pr lic ins y b Un An Pu
l ta To
ly lic te ub On iva rP re Pr e a h h it dic Ot W Me ith W
Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 81 81
40
Adults with Poorly Controlled Chronic Diseases, by Race/Ethnicity, Family Income, and Insurance Status, 19992004
Percent of adults (ages 18+) with diagnosed diabetes with HbA1c level 9%
100
Percent of adults (ages 18+) with hypertension with blood pressure 140/90 mmHg
100
79
75
75
64 63
66
71 60 64
67
69 59
50
37
50
25
23 17 12
26 15 15 14
22
19
25
l ic k te ta ac pan hi To Bl W s Hi
r* * * gh ddle poo Hi i ar M Ne
* d ed or re ur Po Insu ins Un
l te ta hi To W
k ic ac pan Bl s Hi
* * r* gh ddle poo Hi ar Mi Ne
d * d re or re Po nsu insu I Un
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 82
Receipt of All Three Recommended Services for Diabetics, by Race/Ethnicity, Family Income, Insurance, and Residence, 2004
Percent of diabetics (ages 40+) who received HbA1c test, retinal exam, and foot exam in past year
Total W hite Black Hispanic
47 49 47 39 58 42 38 38 47
NA
400%+ of poverty 200%399% of poverty 100%199% of poverty <100% of poverty
Private* Uninsured*
Urban** Rural** 0 20 40
48 47
60 80 100
*Insurance for people ages 4064. ** 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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 83
41
EQUITY: SAFE CARE
Medical, Medication, and Lab Errors, by Race/Ethnicity, Income, and Insurance Status, 2007
Percent of adults ages 1864 reporting medical mistake, medication error, or lab error in past two years
40
20
20
20
22 16 18
24 18
25
Total
White
Black
Hispanic
Above average
Below average
Insured all year
Uninsured any time
Race/ethnicity
Income
Insurance status
Data: 2007 Commonwealth Fund International Health Policy Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 84
EQUITY: SAFE CARE
Select AHRQ Patient Safety Indicators, 2004

Postoperative pulmonary embolus or deep vein thrombosis 8.4 10.7 8.2 6.4
Risk adjusted rate per 1,000 discharges* RACE/ETHNICITY

White Black Hispanic Asian/Pacific Islander
Failure to rescue 122.3 116.8 130.4 140.3
Decubitus ulcers 24.3 36.0 27.2 22.4
Selected infections due to medical care 1.7 1.9 1.2 1.4
Postoperative sepsis 10.4 10.9 11.3 12.4
MEDIAN INCOME OF PATIENT ZIPCODE

Less than $25,000 $45,000 or more
124.0 119.4
29.6 26.5
1.6 1.6
10.2 9.2
14.9 9.8
INSURANCE
Private insurance Uninsured/self pay
112.2 135.6
19.0 17.6
1.2 1.3
7.8 7.9
8.7 9.2
PATIENT RESIDENCE
Urban Rural
121.5 111.3
29.8 21.7
1.7 1.2
10.0 7.6
10.9 10.3
* Rates exclude complications present on admission and are adjusted for gender, comorbidities, and diagnosis-related group clusters. Data: Race/ethnicityHCUP, State Inpatient Database (AHRQ 2007b); income area, insurance, and patient residence Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (AHRQ 2007a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 85
42
EQUITY: SAFE CARE
Pressure Sores Among High-Risk and Short-Stay Residents in Nursing Facilities by Race/Ethnicity, 2005
Percent of nursing home residents with pressure sores
40
W hite
Black
Hispanic
Asian/PI
AI/AN
25 20
20
24
22
21
17 13 14 11 13
High risk residents
Short-stay residents
PI=Pacific Islander; AI/AN=American Indian or Alaskan Native. Data: Nursing Home Minimum Data Set (AHRQ 2007b). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 86 86
EQUITY: PATIENT-CENTERED, TIMELY CARE
Waiting Time to See Doctor When Sick, by Race/Ethnicity, Income, and Insurance Status, 2007
Percent of adults ages 1864 who reported waiting six or more days for an appointment when sick or needed medical attention
40
36 28 20 16 16
26 18
27
20
Total
White
Black
Hispanic
Above average
Below average
Insured all year
Uninsured any time
Race/ethnicity
Income
Insurance status
43
EQUITY: PATIENT-CENTERED, TIMELY CARE
DoctorPatient 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
Total
10 9 11 12 14 8 16 9 19 10 7
0 5 10 15 20
White Black His panic As ian
400+%of poverty <100%of poverty
Private insurance* Unins ured*
Urban** Rural**
* Insurance for people ages 1864. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants. Data: Medical Expenditure Panel Survey (AHRQ 2007b). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 88
EQUITY: COORDINATED AND EFFICIENT CARE
Duplicate Medical Tests, by Race/Ethnicity, Income, and Insurance Status, 2007

Percent reporting that doctor ordered test that had already been done in past two years
30
20 14 10 13 13 15 11
19 17 11
Total
White
Black
Hispanic
Above average
Below average
Insured all year
Uninsured any time
Race/ethnicity
Income
Insurance status
44
Test Results or Medical Record Not Available at Time of Appointment, by Race/Ethnicity, Income, and Insurance Status, 2007
Percent reporting test results/records not available at time of appointment in past two years
30 23 20 20 17 15 12 10 14 20 23
Total
White
Black
Hispanic
Above average
Below average
Insured all year
Uninsured any time
Race/ethnicity
Income
Insurance status
Went to Emergency Room for Condition That Could Have Been Treated by Regular Doctor, by Race/Ethnicity, Income, and Insurance Status, 2007
Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available
30 22 20 15 15 11 10 11 13 22 20
Total
White
Black
Hispanic
Above average
Below average
Insured all year
Uninsured any time
Race/ethnicity Data: 2007 Commonwealth Fund International Health Policy Survey.
Income
Insurance status
91
45
Ambulatory CareSensitive (Potentially Preventable) Hospital Admissions, by Race/Ethnicity and Patient Income Area, 2004/2005*
Adjusted rate per 100,000 population Heart failure
1000
Diabetes**
904
Pediatric asthma
667
520
500
554 444
392
374
390
240
178
173
98
0
144
110
NA
0 + ic n 00 ck 00 0 5, la pa 5, B is $2 H $4 <
ite h W
e hit W
k ac Bl
0 + ic 00 ,00 an 25 5,0 sp Hi $4 <$
e hit W
k ac Bl
0 + ic 00 ,00 an 25 5,0 sp Hi $4 <$
* 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/ethnicityHealthcare Cost and Utilization Project, State Inpatient Databases and National Hospital Discharge Survey (AHRQ 2007b); Income areaHCUP, Nationwide Inpatient Sample (AHRQ 2007a, retrieved from HCUPnet at http://hcupnet.ahrq.gov).
92 92
EQUITY: ACCESS
Nonelderly Adults with Time Uninsured During the Year, by Family Income and Race/Ethnicity, 2004
Percent of nonelderly adults (ages <65) who had no health insurance coverage sometime during the year
100
W hite
Black
Hispanic
75 54 50 28 25 21 11 0 Total High income Middle income Near poor Poor 17 18 22 43 26 42 37 38 43 33
51
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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 93 93
46
EQUITY: ACCESS
Cost-Related Access Problems, by Race/Ethnicity, Income, and Insurance Status, 2007

Percent of adults (ages 1964) who had any of four access problems* in past year because of cost
Total 45
White Black Hispanic
46 45 46
400%+ of poverty 200%399% of poverty <200% of poverty
26 50 61
Insured all year Uninsured during year 0 20
35 72 40 60 80 100
* 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 94 94
SYSTEM CAPACITY
SECTION 6. SYSTEM CAPACITY TO INNOVATE AND IMPROVE The Scorecard addresses but does not score indicators for 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
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 95
47
SYSTEM CAPACITY
Primary Care Medical Residency Positions Filled by U.S. Medical School Graduating Seniors and Other Applicants: 1997-2007
Positions filled by other applicants* 5,000 Positions filled by U.S. medical school graduating seniors
4,004
4,000 837 3,000 1,155 2,000 3,167 1,000 1,967 1,648 1,602 1,384
3,122
3,032
3,008
1,406
1997
2002
2006
2007
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 96
SYSTEM CAPACITY
Hospital Employee Satisfaction, 2006

Overall Satisfaction Score
100 Registered Nurses All Employees
75 58.3 50 60.3 61.2 63.1
65.8
66.2
68.0
68.8
71.4
71.5
25
0 10th percentile 25th percentile 50th percentile 75th percentile 90th percentile
Data: 2006 Press Ganey Associates, Inc. Data represent the experiences of 121,882 employees across 132 facilities in 2006. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 97 97
48
SYSTEM CAPACITY
Nursing Home Workforce Satisfaction, 2006

Composite satisfaction scores (average of 21 survey items) where 100=excellent and 0=poor
100 Nursing assistants* Nurses All nursing home employees
75 51 52 55 58 59 60
64 66 65
50 38 37 25
44
44 44
49
0 10th percentile 25th percentile 50th percentile 75th percentile 90th percentile
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 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 98
SYSTEM CAPACITY
Hospital Nursing Staff Vacancy Rates, 2000

Percent
20
15
15
14 12 12 11 10 9 9
10
10
0 National average Critical care Medical/ Surgical ER Obstetrics W est South Northeast Midwest
Type of acute care
Region
Data: American Organization of Nurse Executives 2000 Acute Care Hospital Survey of RN Vacancies and Turnover Rates. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 99 99
49
SYSTEM CAPACITY
Nursing Homes: Turnover Rates of Certified Nursing Aides in Nursing Homes, 2002
Rate of terminations to established positions
150 119 100 71 136
50 21
38
0 National average Lowest state Lowest 10% states Highest 10% states Highest state
Data: 2002 American Health Care Association Survey of Nursing Staff Vacancy and Turnover in Nursing Homes (AHCA 2002). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 100 100
SYSTEM CAPACITY
Nursing Home Staff Hours Per Patient Day

Distribution by Direct Care Staff
Recommended Threshold#
90th %ile States
10th %ile States
US Median
2.80
2.98 2.3
2
1.30 1.40 1.1
2.00
0.75 0.66 0.10 0.3
0.86
0
Registered Nurses All Licensed Nursing Staff* Nursing Aides
# 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 101 101
50
SYSTEM CAPACITY
Hospital Organizational Culture: Staff Perceptions of Teamwork and Learning Environment, 2007
Percent of staff giving positive responses
Average 100 79 75 71 70 61 50 57 44 44 32 25 96 87 80 72 56 Best hospital 94 90th %tile hospitals 91 82 10th %tile hospitals
0 Teamwork within units Organizational learning & continuous improvement Teamwork across units Nonpunitive response to error
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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 102
SYSTEM CAPACITY
Adoption of Culture Change by Nursing Homes, 2007

Categories of Nursing Homes, by Extent of Culture Change Adoption
Culture change definition* completely or for the most part describes nursing home 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
TRADITIONAL 43%
CULTURE CHANGE ADOPTERS 31%
CULTURE CHANGE STRIVERS 25%
Culture change definition* describes nursing home only in a few respects or 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 103
51
SYSTEM CAPACITY
National Health Expenditures Spent on Public Health Activities Compared with Insurance Administration Costs
Dollars (in billions)
175 150 129.0 125 100 81.8 75 53.9 50 25 0 Government public health activities Insurance administrative costs 43.4 58.7
Percent growth from 2000 to 2006

2004 2006
145.4
2000
100 78
80
60
55
40
35
20
0
National health expenditures Government public health activities Insurance administrative costs
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). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 104 104
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/ 2005. National Healthcare Quality Report, 2005. Data Tables Appendix. http://www.ahrq.gov/qual/nhqr05/ 2004. National Healthcare Quality Report, 2004. Data Tables Appendix. http://www.ahrq.gov/qual/nhqr04/ 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 Childrens 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. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 105
52
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.
106
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COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM

National Scorecard on U.S. Health System Performance, 2008

The Commonwealth Fund Commission on a High Performance Health System Membership

The Commonwealth Fund

Scores: Dimensions of a High Performance Health System

2006 Revised 2008

Mortality Amenable to Health Care

Infant Mortality Rate

International Comparison, 2004

11.1 10.2 9.9 9.9 9.6 10.1

d d n ay en da ark pa lan lan rw na ed nm Ja Ice Ca No Fin Sw De

Healthy Life Expectancy at Age 60, 2002

S Jap w itz an er la nd Fr an ce S pa S in w ed A en us tr al ia Ita A ly us tr C ia an a B da el gi G um er m an y N or w ay Ic el an Fi d N nl et an he d r N ew lan d Ze s al a nd U ni G te r d ee K ce in U gd ni om te d S ta te P s or tu ga l Ir el C D and ze en ch m R ark ep ub lic

Working-Age Adults with Health Limits on Activities or Work

Top 10% states Bottom 10% states

W hite Black Hispanic

400%+ of poverty <100% of poverty

Private insurance Uninsured

QUALITY: EFFECTIVE CARE

QUALITY: EFFECTIVE CARE

Receipt of Recommended Screening and Preventive Care for Adults

U.S. Variation 2005

QUALITY: EFFECTIVE CARE

Immunizations for Young Children

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

<100% of poverty 100%+ of poverty Insured all year

QUALITY: EFFECTIVE CARE

Top 10% states Bottom 10% states

W hite Black Hispanic

400%+ of poverty <100% of poverty

Private insurance Uninsured 0 20

QUALITY: EFFECTIVE CARE

Adults with Major Depressive Episode Who Received Treatment

U.S. Variation 2006

White Black Hispanic Private Medicaid Medicare** Uninsured 0 20 40

QUALITY: EFFECTIVE CARE

Top 10% states Bottom 10% states

W hite Black Hispanic

400%+ of poverty <100% of poverty

Private insurance Uninsured 0 20

QUALITY: EFFECTIVE CARE

Chronic Disease Under Control: Diabetes and Hypertension

Percent of adults (age 18+)

Diabetes under control*

High blood pressure under control**

QUALITY: EFFECTIVE CARE

Chronic Disease Under Control: Managed Care Plan Distribution, 2006

0 Private Medicare Medicaid Private Medicare Medicaid

QUALITY: EFFECTIVE CARE

QUALITY: EFFECTIVE CARE

QUALITY: EFFECTIVE CARE

Acute myocardial infarction

100 100 100

100 100 100

QUALITY: COORDINATED CARE

QUALITY: COORDINATED CARE

Adults with an Accessible Primary Care Provider

U.S. Variation 2005

QUALITY: COORDINATED CARE

Top 10% states Bottom 10% states

W hite Black Hispanic

400%+ of poverty <100% of poverty

Private insurance Uninsured 0 20

QUALITY: COORDINATED CARE