Scorecard Methods

The Commonwealth Fund’s 2020 Scorecard on State Health System Performance evaluates states on 49 performance indicators grouped into four dimensions:

  • Access and Affordability (7 indicators):
    includes rates of insurance coverage for children and adults, as well as individuals’ out-of-pocket expenses for health insurance and medical care, cost-related barriers to receiving care, and receipt of dental visits.
  • Prevention and Treatment (15 indicators):
    includes measures of receipt of preventive care and needed mental health care, as well as measures of quality in ambulatory, hospital, postacute, and long-term care settings.
  • Potentially Avoidable Hospital Use and Cost (14 indicators; including several measures reported separately for distinct age groups):
    includes indicators of hospital and emergency department use that might be reduced with timely and effective care and follow-up care, as well as estimates of per-person spending among Medicare beneficiaries and working-age adults with employer-sponsored insurance.
  • Healthy Lives (13 indicators):
    includes measures of premature death, health status, health risk behaviors (including smoking and obesity), tooth loss, and state public health funding.

Income Disparity Dimension

This year, the Scorecard reports on performance differences within states associated with individuals’ income level for 11 of the 49 indicators where data are available to support a population analysis by income; these indicators span three of the four dimensions. For each indicator, we measure the difference between rates for a state’s low-income population (generally under 200% of the federal poverty level) and higher-income population (generally more than 400% of the federal poverty level). States are ranked on the relative magnitude of the resulting disparities in performance.

The income disparity indicators are different than those used in the 2019 Scorecard; hence, these disparity rankings are not strictly comparable to those published previously.

Race Equity Data

This year, the Scorecard includes racial and ethnic equity data based on within-state differences between racial and ethnic communities. These data are included for informational purposes but are not ranked. We’ve included racial and ethnic differences in 10 of the 49 indicators where data are available to support a population analysis by race and/ or ethnicity; these indicators span three of the four dimensions. Rates for all available races and ethnicities can be found in Appendix H1.

The following principles guided the development of the Scorecard:

Performance Metrics

The 49 metrics selected for this report span health care system performance, representing important dimensions and measurable aspects of care. Where possible, indicators align with those used in previous state Scorecards. Several indicators used in previous versions of the Scorecard have been dropped either because all states improved to the point where no meaningful variations existed (for example, measures that assessed hospitals on processes of care) or the data to construct the measures were no longer available (for example, hospitalizations for children with asthma). New indicators have been added to the Scorecard series over time in response to evolving priorities. Refer to the About page for more detail on changes in indicators.

Measuring Change over Time

We were able to track performance over time for 43 of the 49 indicators. Not all indicators could be trended because of changes in the underlying data or measure definitions.

There were generally five years between indicators’ baseline and current-year data observation, though the starting and ending points depended on data availability (see Appendix A1).

We considered a change in an indicator’s value between the baseline and current-year data points to be meaningful if it was at least onehalf (0.5) of a standard deviation larger than the indicator’s combined distribution over the two time points — a common approach used in social science research. We did not formally evaluate change over time for indicators in the income dimension

Data Sources

Indicators draw from publicly available data sources, including government-sponsored surveys, registries, publicly reported quality indicators, vital statistics, mortality data, and administrative databases. The most current data available were used in this report whenever possible. Appendix A1 provides detail on the data sources and time frames.

Scoring and Ranking Methodology

For each indicator, a state’s standardized z-score is calculated by subtracting the 51-state average (including the District of Columbia as if it were a state) from the state’s observed rate, and then dividing by the standard deviation of all observed state rates. States’ standardized z-scores are averaged across all indicators within the performance dimension, and dimension scores are averaged into an overall score. Ranks are assigned based on the overall score. This approach gives each dimension equal weight and, within each dimension, it weights all indicators equally. This method was introduced in the 2018 Scorecard, and it better accommodates the different scales used across Scorecard indicators (for example, percentages, dollars, and population based rates). This method also aligns with methods used in the Commonwealth Fund’s international health system rankings.

As in previous scorecards, if historical data were not available for a particular indicator in the baseline period, the current year data point was used as a substitute, thus ensuring that ranks in each time period were based on the same number of indicators.

Regional Comparisons

The Scorecard groups states into the eight regions used by the Bureau of Economic Analysis to measure and compare economic activity. The regions are: Great Lakes (Illinois, Indiana, Michigan, Ohio, Wisconsin); Mid-Atlantic (Delaware, District of Columbia, Maryland, New Jersey, New York, Pennsylvania); New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont); Plains (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota); Rocky Mountain (Colorado, Idaho, Montana, Utah, Wyoming); Southeast (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia); Southwest (Arizona, New Mexico, Oklahoma, Texas); and West (Alaska, California, Hawaii, Nevada, Oregon, Washington).