A presentation given by Eric Schneider and Douglas McCarthy of The Commonwealth Fund to the Utah State Legislature – Health and Human Services Committee on August 23, 2017.

1. Eric Schneider, MD, MSc, FACP
Senior Vice President for Policy and Research, The Commonwealth Fund
Douglas McCarthy, MBA
Senior Research Director, The Commonwealth Fund
Utah State Legislature – Health and Human Services Committee
August 23, 2017
Using Measurement to
Improve Performance:
Insights from Scorecards

2. 2
GDP refers to gross domestic product.
Source: OECD Health Data 2016. Data are for current spending only, and exclude spending on capital formation of health
care providers.
Health Care Spending as a Percentage
of GDP, 1980–2014
0
2
4
6
8
10
12
14
16
18
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
United States (16.6%)
Switzerland (11.4%)
Sweden (11.2%)
France (11.1%)
Germany (11.0%)
Netherlands (10.9%)
Canada (10.0%)
United Kingdom (9.9%)
New Zealand (9.4%)
Norway (9.3%)
Australia (9.0%)
Percent

3. 3
UK AUS
NETH
NZ NOR
SWIZ SWE GER
CAN
FRA
US
Note: See the methodology appendix for a description of how the performance score is calculated.
Health Care System Performance Scores
of Eleven High-Income Countries
Eleven-country average
Higher performing
Lower performing

4. 4Source: Mirror Mirror Teleconference, Eric C. Schneider, July 13, 2017
• Access and Affordability (11th)
Americans more likely to report financial barriers to care
• Health care outcomes (11th)
The U.S. has higher rates of mortality
• Equity (11th)
Larger disparities in performance between lower-income versus higher-income people
in the U.S.
• Administrative Efficiency (10th)
Doctors and patients in the U.S. more likely to report problems related to insurance
approvals and billing
• Prevention and Treatment (5th)
Higher rates of screening and lifestyle counseling in the U.S.
Why is U.S. Performance Last among
the Eleven?

5. 5
State Health Care System Scorecards
highlight opportunities to improve
Top quartile (13 states)
Second quartile (11 states + D.C.)
Third quartile (13 states)
Bottom quartile (13 states)
Overall
Rank
Access & Affordability (6 indicators)
Prevention & Treatment Quality (18)
Avoidable Hospital Use & Costs (9)
Healthy Lives (11)
Equity (19 income; 16 race/ethnicity)
Rank
Rank
Rank
Rank
Rank
44

6. 6
Leading states offer targets for improvement
Note: States highlighted in green expanded their Medicaid programs under the Affordable Care Act as
of Jan. 1 2015. “n.c.” means no change in overall rank.
1 Vermont 1 1 1 1 1 n.c.
2 Minnesota 1 1 1 1 1 ↓1
3 Hawaii 1 2 1 1 1 n.c.
4 Rhode Island 1 1 2 1 1 ↑3
5 Massachusetts 1 1 4 1 1 ↓1
6 Colorado 2 2 1 1 1 ↑5
6 Iowa 1 1 2 2 1 n.c.
8 Connecticut 1 1 4 1 1 ↓1
8 New Hampshire 1 1 3 2 1 ↓3
10 Washington 2 2 1 1 1 ↑6
11 Wisconsin 2 1 2 2 3 ↑1
12 Maryland 1 2 3 2 2 ↑2
12 New York 2 2 3 1 1 ↑8
14 California 2 3 2 1 1 ↑12
15 Delaware 1 1 3 3 2 ↓1
15 Maine 2 1 2 3 2 ↓6
15 Nebraska 3 2 2 2 2 ↓6
15 South Dakota 3 1 1 3 2 ↑1
15 Utah 4 3 1 1 2 ↓3
20 District of Columbia 1 2 3 3 2 ↑2
20 North Dakota 3 2 2 2 2 ↓4
22 New Jersey 2 2 4 1 2 n.c.
22 Oregon 3 3 1 2 2 ↑2
22 Pennsylvania 1 1 3 3 3 ↓6
25 Virginia 2 2 2 2 2 ↓1
26 Idaho 4 3 1 2 3 ↓6
27 Illinois 2 2 4 2 2 ↑2
28 Kansas 3 2 3 3 3 ↓1
29 Michigan 2 2 4 3 3 ↑1
29 Montana 3 3 1 3 3 ↑1
29 New Mexico 3 4 1 3 2 ↑1
32 Arizona 4 4 1 2 2 ↑4
32 Ohio 2 2 3 3 3 ↓2
32 Wyoming 3 3 2 2 4 ↓4
35 North Carolina 3 2 2 3 3 ↑1
36 Alaska 4 4 1 3 3 ↓2
37 Missouri 3 3 3 4 3 ↓3
38 West Virginia 2 2 4 4 3 ↑3
39 Florida 4 4 4 2 3 n.c.
39 Kentucky 2 3 4 4 4 ↑8
41 Georgia 4 4 2 4 4 ↑4
41 South Carolina 3 4 2 4 4 n.c.
41 Texas 4 4 3 2 3 n.c.
44 Indiana 3 3 3 4 4 ↑1
44 Tennessee 3 3 3 4 4 ↓6
46 Nevada 4 4 2 3 4 ↓5
47 Alabama 3 4 4 4 4 ↓8
48 Arkansas 4 4 4 4 4 ↑1
49 Louisiana 4 4 4 4 4 ↓1
49 Oklahoma 4 3 4 4 4 ↑1
51 Mississippi 4 4 4 4 4 n.c.
Top Quartile
Second Quartile
Third Quartile
Bottom Quartile

7. 7
NOTE: The 2017 Scorecard rankings generally reflect 2014 or 2015 data. The 2017 State Scorecard added or revised several
performance measures relative to what was reported in previous Scorecard reports; therefore, overall and dimension
rankings are not strictly comparable to previous reports.
Source: D. Radley, D. McCarthy, and S. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State
Health System Performance 2017 Edition, The Commonwealth Fund, March 2017.
How Utah Compares to Other States
UTAH COLO. MINN.
Overall 15 6 2
Access & Affordability 40 23 3
Prevention & Treatment 29 14 7
Avoidable Hospital Use & Cost 3 7 10
Healthy Lives 4 5 1
Equity 18 8 5

8. 8
21
9
24
26
17
29
20
9
20
0
5
10
15
20
25
30
35
Adults ages 18–64 who
report fair/poor health
or activity limitations
(2015)
Adults who smoke
(2015)
Adults ages 18-64 who
are obese (2015)
Utah U.S. Average Best State
NOTE: The four indicators shown above are a subset of the 11 indicators that make up the Healthy Lives dimension.
SOURCE: D. Radley, D. McCarthy, and S. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on
State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017.
Healthy Lives
61
84
54
0
10
20
30
40
50
60
70
80
90
100
Mortality amenable to
health care: premature
deaths per 100,000
population (2013-14)
Rate per 100,000 Percent
#6 #3
#1
#3

9. 9
$8,207
$4,508
$9,025
$4,736
$5,586
$3,347
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
Total Medicare (Parts
A&B) reimbursements*
per beneficiary
(ages 65+)
Total reimbursements*
per enrollee with
employer-sponsored
insurance (ages 18–64)
Utah U.S. Average Best State
NOTES: The four indicators shown above are a subset of the nine indicators that make up the Avoidable Hospital Use &
Cost dimension. *Spending estimates exclude prescription drug costs and are adjusted for regional wage differences.
SOURCE: Data shown are for 2015 and represent updated and most recently available data from sources used in The
Commonwealth Fund Scorecard on State Health System Performance, 2017.
Avoidable Hospital Use and Costs of Care
38
14
66
27
33
10
0
10
20
30
40
50
60
70
Hospital admissions for
ambulatory-care
sensitive conditions
(ages 75+)
Hospital 30-day
readmissions
(ages 65+)
Rate per 1,000 Medicare beneficiaries (2015)
#4
#2
#20
#20

10. 10
74
68 68
90
78
68
72
8789
77
81
90
0
10
20
30
40
50
60
70
80
90
100
Adults with a usual
care provider (2015)
Adults received
recommended cancer
screenings (2014)
Young children
received all
recommended
vaccinations (2015)
Hospital patients
received discharge
instructions (2015)
Utah U.S. Average Best State
NOTE: The four indicators shown above represent a subset of the 18 indicators that make up the Scorecard’s Prevention &
Treatment dimension.
SOURCE: D. Radley, D. McCarthy, and S. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State
Health System Performance 2017 Edition, The Commonwealth Fund, March 2017.
Prevention and Treatment Quality
Percent
#41
#23 #41
#1

11. 11
Access & Affordability
Source: D. Radley, D. McCarthy, and S. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State
Health System Performance 2017 Edition, The Commonwealth Fund, March 2017. Results displayed in the Commonwealth
Fund’s Health System Data Center, http://datacenter.commonwealthfund.org/scorecard/state/46/utah/
UTAH

12. 12
UT
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FLGA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
VA
VT
WA
WI
WV
WY
R
2
= 0.76
16111621263136414651
16111621263136414651
Source: Based on data reported in: D. Radley, D. McCarthy, and S. Hayes, Aiming Higher: Results from the Commonwealth
Fund Scorecard on State Health System Performance 2017 Edition, The Commonwealth Fund, March 2017.
State Rankings on Access and Quality Dimensions
State
Ranking on
Prevention
& Treatment
Dimension
State Ranking on Access Dimension Top
Rank
Top
Rank
Bottom
Rank

13. 13
NOTE: The table shows the estimated impact if this state's performance improved to the rate of the best-performing state
for selected Scorecard indicators.
Source: D. Radley, D. McCarthy, and S. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State
Health System Performance 2017 Edition, The Commonwealth Fund, March 2017.
What if Utah was the best-performing US state?
People Impact
171,113 more adults would be covered by health insurance
67,668 more children would be covered by health insurance
125,402 fewer adults would skip needed health care because of cost
187,448 fewer individuals would face high out-of-pocket medical spending
313,506 more adults would have a usual health care provider
102,794 more adults would receive recommended cancer screenings
9,525 more young children would receive all recommended vaccines
4,912 fewer Medicare beneficiaries would receive an unsafe drug
382 fewer individuals would commit suicide

14. 14
Action insights from high-performing states*
• Government leadership
• Collaboration among stakeholders
• Transparency of price and quality information
• Congruent policies that foster system improvement
Notable strengths of Utah
• Efficient use of resources and healthier population than most other
states
Opportunities for improvement
• Access, affordability, prevention and treatment
How to proceed in Utah?

15. 15
• Reinsurance program via ACA’s 1332 “Innovation” Waiver Program
• July 2017 – CMS approved waiver for Alaska’s reinsurance program
• Program premiums are expected to be 20 percent lower in 2018 than they would
be otherwise
• 1,460 additional individuals are expected to gain coverage
• Premium relief for those who don’t qualify for tax credits
• Minnesota – people buying individual coverage can get a 25% premium
subsidy if they don’t receive federal advanced premium tax credits
(APTC)
• Implement Medicaid expansion
How States Like Utah Can Make
Coverage More Affordable
• Alaska Reinsurance Program: http://healthaffairs.org/blog/2017/07/12/aca-round-up-cms-approves-alaska-
1332-reinsurance-waiver-ceases-premium-outlier-reviews/
• Minnesota Health Insurance Premium Subsidy: https://mn.gov/mmb/minnesota-health-insurance-premium-
relief/

16. 16
System design insights from high-performing
countries
• Expand insurance coverage
• Strengthen primary care
• Reduce administrative burdens for patients and doctors
• Reduce income-related barriers and invest in social
services
Achieving a high performance health system
involves several related changes
Source: Schneider EC and Squires D, New England Journal of Medicine

17. 17
Discussion

18. 18
Downloadable
Profile
Customizable
Benchmarking
tools and
comparisons
Standard
Benchmarking
tools
http://datacenter.commonwealthfund.org

19. 19
Health Care System Performance
Measured Using 72 Indicators Across
5 Domains
• Access
• Administrative efficiency
• Equity
• Care process
• Health care outcomes
Mirror Mirror 2017
PURPOSE
• To learn how health systems
achieve high performance by
comparing performance of 11
high-income countries
DATA SOURCES
• Annual International Health
Policy surveys of 11 high-income
countries (2014-2016)
• Measures from OECD, WHO,
European Observatory

20. 20
• Goal: to provide benchmarks and trends to inform national, state and local action to
improve health care system performance
• Health System Focus: Builds on previous Scorecards
• 44 indicators organized into 4 dimensions
• Access/affordability; Prevention/treatment; Avoidable hospital use and costs; and Healthy lives
• Equity dimension assesses a subset of indicators by income and race/ethnicity within states
• National data sources including administrative claims, national surveys, and vital statistics available for
states
• 1- to 2-year trend data available for 39 indicators
• Generally from 2013 to 2015, but varies by indicator
• Scoring:
• Each indicator is ranked
• Dimension rank is based on average of indicator ranks
• Overall rank based on average of five dimension ranks
• Estimated gains are based on rates of performance in the top performing state
State Health System Scorecard Methods

21. 21
0
5
10
15
20
25
30
35
NewMexico
Nevada
Arizona
Arkansas
California
Kentucky
Oregon
Washington
WestVirginia
Colorado
NewJersey
Illinois
RhodeIsland
Michigan
NewHampshire
Ohio
NewYork
Delaware
Maryland
NorthDakota
Pennsylvania
Connecticut
Iowa
Minnesota
Hawaii
Vermont
DistrictofColumbia
Massachusetts
Texas
Florida
Georgia
Louisiana
Mississippi
Oklahoma
Alaska
Idaho
Montana
NorthCarolina
SouthCarolina
Alabama
Tennessee
Indiana
Kansas
Missouri
Utah
Wyoming
SouthDakota
Virginia
Maine
Nebraska
Wisconsin
Notes: States are arranged in rank order based on their uninsured rate in 2013. Alaska, Indiana, Louisiana, and Montana
expanded their Medicaid programs after Jan. 1, 2015.
Data: U.S. Census Bureau, 2013 and 2015 One-Year American Community Surveys. Public Use Micro Sample (ACS PUMS).
Source: D. Radley, D. McCarthy, and S. Hayes, Aiming Higher: Results from the Commonwealth Fund Scorecard on State
Health System Performance 2017 Edition, The Commonwealth Fund, March 2017.
States that Expanded Medicaid Saw
Greatest Reductions in Rates of
Uninsured Working-Age Adults
percent
States that expanded Medicaid
as of January 1, 2015
States that had not expanded Medicaid as
of January 1, 2015
2015
2013
Utah 2013
18%
Utah 2015
14%