An Advocate's Guide to State-Level Healthcare Value Data

Many Americans find it alarmingly difficult to get good value for their healthcare dollar. The United States spends more than any other country on healthcare. Excess healthcare spending crowds out other important purchases and burdens individuals, employers and governmental budgets.

Strong data must support efforts to ensure that the money spent by governments, payers and households leads to high-quality care, good outcomes and patient experience. Data can help advocates and policymakers understand the problems causing poor healthcare value and tell us whether new methods of provider payment and other interventions are working.  

States are a key system actor likely to be at the forefront of meaningful progress on healthcare cost and value issues. The specific conditions that give rise to high prices, unnecessary services and uneven quality vary tremendously between different geographic areas of the country.

This guide describes the major dimensions of healthcare value measurement and points to readily available state-level data resources that begin filling in the picture of how well states are performing on healthcare value for their residents—and where key data sources are lacking.  

What are the Dimensions of Healthcare Value?

Healthcare value is getting good quality care for a fair price. We must stop overpaying at the household, employer or governmental level because, at the end of the day, it’s all the consumer’s money.

It is also about having the infrastructure in place that enables consumers to navigate our healthcare system safely and confidently. This means that data on price and quality is trusted, actionable and readily available so that the risk of encountering poor performers, or an outrageously inflated price, is minimized.

Finally, a properly working healthcare system is sensitive to consumers’ varying ability to pay for the care they need. Healthcare, after all, is not a luxury, but a vital service necessary for life and quality of life.

With this description of healthcare value in mind, we believe states should use the following broad categories to measure healthcare value for their residents:

• Spending and Cost
• Affordability
• Health Outcomes
• Medical Harm
• Patient Experience

To make advocates lives easier, we also include a guide to Data Aggregation Tools.

 

Spending and Costs

It’s important to measure total annual healthcare spending in a state for the most complete picture of progress on healthcare value, but it is also important to separate spending growth into its utilization and price components. Are we overspending on low-value care? Or perhaps under-spending on high-value care? Finally, it is critical to look for particular price or utilization “hot spots” (specific services, geographic areas or populations) that need attention within a state.

Compared to other dimensions of healthcare value, it is generally difficult to obtain state-level spending data. Readily available utilization data often reflects just the Medicare-enrolled population. Premium data is not a good substitute for data on underlying medical costs as changes in average premium also reflect changes in benefit design and provider network composition.  

We recognize that price and quality transparency tools can help consumers better navigate the cost of care.  However, such tools are beyond the scope of this article, as prices are generally beyond the scope of health system and provider performance which is the primary concern of this 

Measure	What is It?	Primary Data Source
Per capita personal healthcare consumption expenditures (PCE)	Per person healthcare spending, by state, by year. Estimates include nursing home care spending.The Bureau of Economic Analysis website offers an interactive data viewer	Bureau of Economic Analysis (BEA)
Potentially avoidable emergency department visits among Medicare beneficiaries	There are many conditions that should rarely result in trips to the ER when appropriate ambulatory care is provided. Avoidable admissions are therefore a measure of the quality of ambulatory care in a state.Available by state from the Commonwealth Fund's U.S. Health System Data Center	Medicare Standard Analytic Files (claims data)
Use of high-value care: Adults ages 50 and older who received recommended screening and preventive care	Use of preventive care in adults.  Somewhat older data is available for the use of preventive care in children.Available by state from the Commonwealth Fund's U.S. Health System Data Center	The Behavioral Risk Factor Surveillance System (BRFSS)

What’s missing? States need to do a better job separating spending growth into its utilization and price components (as is done nationally by the Health Care Cost Institute); tabulation of low- and high value service use in a state. Medicare claims data can be used to do this (requires technical skills) but Medicare price and utilization patterns are generally not a good predictors of variation in the privately insured population. A handful of states have all-payer claims databases that contain data from all insurers and provide a rich repository of spending and utilization data, but far too many states don’t have this critical resource.

Affordability

Unaffordable prices for care and unaffordable premiums can lead consumers to delay getting needed care, cause unwelcome budgetary tradeoffs, medical debt and sometimes bankruptcy.  

Our nation doesn’t have a standard definition of affordability for healthcare, and few states have taken up the question. For now, the metrics below serve as strong signals of affordability problems. For example, delaying care due to concerns about cost is a fairly direct signal of affordability problems. Not having health insurance or being under-insured are also strong indicators of possible affordability problems.  

 

Measure	What is It?	Primary Data Source
Insurance Coverage	Reliable estimates of rates of uninsurance, private insurance and public insurance can be derived from the American Community Survey (ACS).   Available from the SHADAC data center which allows users view specific rates by income, race, ethnic and other demographic characteristics	American Community Survey (ACS)
Avoided care due to cost	The percent of adults in a state who at some point during the year went without healthcare due to cost Available by state from the Commonwealth Fund's U.S. Health System Data Center. Available for sub-state areas from the CDC’s Chronic Disease and Health Promotion Data & Indicators interactive data viewer	The Behavioral Risk Factor Surveillance System (BRFSS)
Individuals under age 65 with high out-of-pocket medical costs relative to their annual household income	Measures the debt burden placed upon working age Americans by healthcare costs. Available from the Commonwealth Fund's U.S. Health System Data Center	Current Population Survey - Annual Social and Economic Supplement (CPS)
Made changes to medical drugs because of cost in past year	Measures the degree to which the cost of care prevents patients from obtaining and using drugs as prescribed by their physician. Available from the SHADAC data center.	The National Health Interview Survey (NHIS)
Trouble paying medical bills in past year	Measures the burden of medical debt in a state. Available from the SHADAC data center.	The National Health Interview Survey (NHIS)

What’s Missing for Affordability? A widely accepted definition of affordability and a system for tracking it; and collecting larger sample sizes for current measures to better understand how the burden of affordability is distributed across state residents.

Health Outcomes

Compared to other dimensions of healthcare value, we have myriad data describing state level population health outcomes. These data range from fairly direct measures of outcomes (such as premature deaths) to more indirect signals, such as those that look at the use of  potentially avoidable care. Potentially avoidable care can signal unnecessary spending and poor outcomes due to mismanagement of the underlying condition.

Measure	What is It?	Primary Data Source
Premature deaths that could have been prevented with effective and timely health care	Available from the Commonwealth Fund's U.S. Health System Data Center	CDC National Vital Statistics System: Mortality Restricted Use File
Infant mortality, deaths per 1,000 live births	The percent of children born who do not survive childbirth in a state. Available from the Commonwealth Fund's U.S. Health System Data Center	Healthcare Cost and Utilization Project (HCUP)
Hospital admissions for pediatric asthma, per 100,000 children	The rate of readmissions for children who present to a hospital for asthma related symptoms. Since most symptoms can be managed with proper treatment and guidance, high readmission rates indicate lower quality of care.   Available from the Commonwealth Fund's U.S. Health System Data Center	Medicare Standard Analytic Files (claims data)
Medicare 30-day hospital readmissions, rate per 1,000 beneficiaries	Available from the Commonwealth Fund's U.S. Health System Data Center	Chronic Conditions Warehouse (CCW)

What’s missing? Broad data on outcomes for the non-Medicare population; demographic detail that would allow us to measure progress on disparities in health outcomes.

Medical Harm

Medical harm refers to all types of medical errors and healthcare-acquired infections. By some estimates, medical harm is the third leading cause of death in the United States. Medical harm, by definition, is largely preventable, causes injury to patients and was proximately caused by the delivery of care. It therefore deserves special attention as a measure of healthcare value. Unfortunately, when measured, this data is often available only at the hospital or provider level, and rarely at the state level.

Measure	What is It?	Primary Data Source
Healthcare-Acquired Infections	Healthcare-acquired infections data include: central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), select surgical site infections (SSI), hospital-onset Clostridium difficile (C. difficile) infections, and hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections). The CDC has state-level annual reports on HAI progress	Centers for Disease Control and Prevention (CDC) Healthcare-Acquired Infections Progress Report

Patient Experience

Consumers deserve to receive healthcare in a manner and setting that is focused on their needs. This means providing a patient experience that is comfortable, welcoming and sensitive to the needs of individual patients. Are medical records readily available? Are appointment times accurate? Does the doctor take the time to clearly explain a diagnosis? These factors and many more define the quality of a patient’s experience.

Measure	What is It?	Primary Data Source
Medicare fee-for-service patients whose health provider always listens, explains, shows respect, and spends enough time with them	Available, by State, from the Commonwealth Fund's U.S. Health System Data Center	Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Hospitalized patients who reported hospital staff always managed pain well, responded when needed help to get to bathroom or pressed call button, and explained medicines and side effects	Available, by State, from the Commonwealth Fund's U.S. Health System Data Center	Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

What’s missing? We need to expand the collection of patient experience data to include the non-Medicare population and non-hospital settings, as well as sample size and demographic detail to permit assessment of disparities in patients’ experience.

Key Data Aggregation Tools

Data Source	Spending	Affordability	Outcomes	Medical Harm	Patient Experience
U.S. Health System Data Center, The Commonwealth Fund http://www. datacenter. commonwealthfund. org/	Medicare reimbursements per enrollee, total single premium per enrolled employee at private-sector establishments that offer health insurance	Adults who went without care because of cost in past year, Individuals under age 65 with high out-of-pocket medical costs relative to their annual household income, Uninsured rate for adults and children	Hospital admissions for pediatric asthma, hospital readmissions, Medicare 30-day hospital readmissions, potentially avoidable ER visits among Medicare beneficiaries, mortality amenable to healthcare, and infant mortality	None	Some limited results from survey data
SHADAC Data Center, State Health Access Data Assistance Center www.datacenter/ shadac.org/Profile	None	Made changes to medical drugs because of cost in past year, needed but delayed medical care due to cost in past year, needed but did not get medical care due to cost in past year, trouble paying medical bills or paying off bills over time in past year, insurance coverage by demographics and family type, average total premium by plan type, employee contributions to premiums by plan type.	None	None	None
State Snapshots, Agency For Healthcare Research and Quality https://nhqrnet. ahrq. gov/inhqrdr/ state/select	None	None	Deaths per 1,000 adult hospital admissions with pneumonia Hospital patients with heart failure discharged home with written instructions or educational material, Avoidable admissions for bacterial pneumonia, Avoidable admissions for angina, Avoidable admissions for chronic obstructive pulmonary disease or asthma , Avoidable admissions for hypertension	None	Adults who had an appointment for routine health care in the last 12 months who sometimes or never got appointments for routine care as soon as wanted, Percent of adults who reported being told what care and services they would get when they first started getting home health care, and more…
CDC Healthcareacquired infections Progress Report http://www.cdc.gov/ hai/surveillance/ progress-repo	None	None	None	Six healthcare-acquired infections tracked	None