The Best & Worst Places to Get Sick

An analysis of health care costs and access in the U.S. by TheStreet and Bundle yielded surprising results.
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Editors note: This story is part of a new partnership between TheStreet and the personal finance site Bundle.



) -- When medical needs arise, are some states better places to be? Are there places where you are out of luck and resigned to less than top-shelf treatment?

It was with these questions in mind that TheStreet and


set out to look at how health care services compare state by state. While other assessments and "top 10 lists" zero in on more granular metrics, our survey focused on top-of-mind items for consumers.

Having your ailment treated quickly and effectively is certainly the primary objective. To that end, you want access to health care and adequate space at hospitals to accommodate you. You want to be able to see a doctor, have specialists available and be assured staffing levels ensure attentive care. Once you feel better and the bills start to arrive, you want to feel you are paying a fair price.

Among the criteria we used was the number of hospital beds per 1,000 people, the degree to which medical care was cost prohibitive, medical staffing levels (encompassing doctors, nurses and physician assistants), the average daily cost of in-patient care and the average per capita spending on health care services annually. The data was culled from's proprietary data on spending, government reports and information aggregated by the

Kaiser Family Health Foundation


The data proved surprising, or even counterintuitive, when smaller, more rural and less populated states ranked as well, or better, than larger states with the brand and cache of world-renowned institutions.

North Dakota and South Dakota -- compared with other states as well as national averages -- topped our list, followed by Pennsylvania, Nebraska and Iowa.

By comparison, Massachusetts and New York, considered global centers of medical innovation, ranked 13th and 19th respectively. Texas, New Mexico, Arizona, California and Nevada anchored the bottom of the list, performing below par in numerous categories.

Dr. Kevin Kavanagh -- founder of

Health Watch USA

, a Kentucky-based advocacy group, and the new website

, focused on medical errors and hospital-acquired infections -- says rural areas and less-populated states aren't necessarily at a disadvantage.

"It depends upon the condition that you have and the overall philosophy of the institution," he says. "Some of the smaller hospitals, if you go in for an appendectomy or hernia repair, for example, do them very commonly and very well. They have very excellent staffing and you may have less of a chance of getting a complication or infection there than going to a large center."

Larger institutions may retain an advantage when it comes to complex procedures and cutting-edge treatments. But having more modern equipment and an inclination to run more tests may not always be in a patient's best interest in terms of health or cost, he says.

"In a large setting, if they have a profit-driven

system and they are doing lots of tests, your results may actually be worse, not better," Kavanagh says.

Dr. Anne-Marie Audet, vice president of Health System Improvement and Efficiency for the

Commonwealth Fund

, a private foundation advocating for improved health care quality and access, agreed size and location are not necessarily related to better or worse care.

"We see variations, and I have to admit we don't always know the underlying reason," she says of the findings in her group's

"state scorecards"

evaluating care. "That's why we go into those states and do case studies to understand what is going on. We have to tease out the characteristics of why they are performing that well."

She cites Wisconsin (No. 23 on our list) as a state performing better than many on various criteria. Success there can be credited in part to a "historical culture that is about collaboration, as opposed to competition." Institutions and doctors alike are very focused on "managing the resources at a community level," she says.


Health care is certainly not something that warrants bargain hunting. When rushed to a hospital, you may have no choice but to go to the nearest institution.

But given a choice, is paying a premium for health care -- or just a prestigious name -- a good value?

Not necessarily.

An investigation of "health care cost trends and cost drivers" earlier this year by Massachusetts' Attorney General's Office found that "the current system of health care payment is not value-based" and "wide disparities in payment levels are not explained by differences in quality or complexity of the health care services provided."

"The present health care marketplace does not allow employers and consumers to make value-based purchasing decisions," the report says. "The system lacks transparency in both price and quality information, which is critical for employers and consumers to be prudent purchasers."

The report, issued in January, looked at Massachusetts health plans and hospitals. It found that prices paid by health insurance companies to hospitals and physician groups "vary significantly within the same geographic area and among providers offering similar levels of service" and that "certain hospitals are able to negotiate higher rates because of their geographic location, subjective consumer 'brand' perceptions and/or specialty service lines."

Small hospitals can be more cost effective. Kavanagh found a large institution in his home state charging $260 for an X-ray while a small, rural hospital in the next county charged $90.


Staffing level per patient is considered by many to be a benchmark of quality care. Appropriate caseloads for doctors and nurses means better case assessments, active monitoring and that medications are administered on time and correctly, as well as with greater control of infections.

Patients also want doctors, residents and nurses to work reasonable hours. Being overworked or tired can lead to mistakes.

In this category, the District of Columbia, South Dakota, Rhode Island and Connecticut led the pack with the greatest percentage of medical professionals for their population.


There are, unfortunately, some quality-based criteria we were unable to include in our rankings.

Infection data, in particular, would ideally have been weighted in. After all, you want to make sure you leave the hospital healthier than when you went in, not acquiring an in-hospital infection or needing to be promptly readmitted.

According to the

U.S. Centers for Disease Control and Prevention

, some 1.7 million infections occur every year in U.S. hospitals. These infections are to blame for upward of 100,000 deaths annually.

It seems a crucial matter for regulatory agencies to be on top of, and one might also hope data would be available to the public. But there is no complete and accurate comparison of either states or individual hospitals when it comes to infection and readmission rates.

Each state has different criteria for how rates are calculated and what types of infections are tallied. Only 27 states collect such data in any meaningful way, and only 20 issue publicly accessible reports.

Although the CDC has collected hospital data for decades, most is submitted voluntarily and kept confidential. The federal

Agency for Healthcare Research and Quality

also crunches such data, but not from all states. It also does not name hospitals.

Available infection data typically focus on central line infections, those caused by catheters leading directly to the heart -- typically used as a longer-term alternative to traditional IV lines. These lines, by nature, are more susceptible to bacterial intrusion, and above-average infection rates may be indicative of broader issues with a hospital's cleanliness and staff protocols.

Data usable from a consumer's perspective on other in-hospital infections, such as MRSA, C. Difficile and sepsis -- the last of which in lethal in nearly half of its instances -- is less common.

Julia Hallisy

, co-founder of the California-based

Empowered Patient Coalition

, is among those pushing for the mandatory reporting of errors and infections. Her group advocates a national clearinghouse with federal oversight, to maintain such data.

"The rallying cry among advocates is that you can't improve what you don't measure," she says. "Medical institutions use the argument that everyone collects data differently and that mandatory reporting would be 'comparing apples and oranges.' If there was a universally applied, scientific reporting platform, this shallow argument would be moot. Everyone needs to be reporting events in the same format to one central agency."

Health care reform legislation will, starting next year, begin phasing in infection data requirements. Other coming changes will link Medicare payments to such factors as patient readmissions and infection rates.

"Health care costs are diving people into bankruptcy," says Lori Nerbonne of

NH Patient Voices

. "We do know that higher quality results in lower cost. It is the complications that happen in hospitals that drive up costs so drastically, along with procedures and surgeries that are unnecessary."


Health care advocates advise using rankings and ratings like the one we devised as a starting point for investigating individual hospitals and clinics.

"People spend time researching cars, restaurant reviews and vacation rentals, but they tend not to do the same with health care simply because they don't know what to do or where to turn," Hallisy says. "The public is definitely coming to the realization that they need to be informed and proactive, but they have few resources to help them achieve these goals."

"It used to be, if you lived here in New Hampshire, that you had to go to Boston for coronary surgery," Nerbonne says. "Now there are four or five hospitals here that are doing it. ... If you are having brain, cardiac or lung surgery, people really need to do their homework."

Among the online resources that offer help to consumers are:

  • The Leapfrog Group for Public Safety, a nonprofit organization based in Washington, D.C., provides information on individual hospitals, much of it submitted voluntarily. Its data, routinely cited by health care advocates, can be found at
  • The Consumer's Union has been a leader in health care data on quality and safety. Among their resources are and
  • The government-run Hospital Compare provides information about hospital compliance with recognized standards of care.
  • To check on a hospital's accreditation status, visit
  • The Robert Wood Johnson Foundation is the nation's largest philanthropy devoted exclusively to improving the health and health care of Americans. Its research and initiatives can be found at It also offers a quantitative ranking of health care among counties at
  • Healthcare Blue Book offers a tool that allows users to compare the cost of specific medical services.

--Written by Joe Mont in Boston.

>To contact the writer of this article, click here:

Joe Mont


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