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Tennessee's health care landscape still ranks among the nation's worst, according to the2014 state health scorecard by the Commonwealth Fund.

Overall, Tennessee ranked 40th out of 50 states and the District of Columbia.

The Scorecard ranks states based on five categories: access, prevention and treatment, avoidable hospital use and cost, healthy lifestyles and equity – meaning availability of services across racial and socioeconomic groups.

The entire Southeast performed poorly. "In some areas, particularly in lower-income areas, people's incomes haven't been keeping up with premiums," said Cathy Schoen, senior vice president for policy, research and evaluation at The Commonwealth Fund.

"That means even insured populations are often facing much higher deductibles and premium copayments, so they're going without care," she said. "Tennesseans are on the high end of that – one out of five adults are saying they went without care because they couldn't afford it."

The study suggests the population in Tennessee is relatively sick and has inadequate access to health care resources. Tennessee performed worst in the "avoidable hospital use and cost" and "healthy lives" categories, ranking 43rd and 46th respectively

In the avoidable hospital use and cost category, Tennessee received low marks because of the high number of Medicare patients who were treated in a hospital when they could have been treated in community clinics instead.

Community-centered care is generally less expensive and often addresses a problem before it escalates to a crisis. For example, people with diabetes who consistently visit clinics would theoretically be more likely to avoid costly medical events, such as going blind or requiring an amputation, which require emergency care.

The "healthy lives" category contributed heavily to the state's low score. One of the indicators in that category is "mortality amenable to health care," which means death from complications that were potentially treatable. Examples include death from diabetes before the age of 50, or death from measles before the age of 14.

Tennessee has a startlingly high rate of infant mortality, at 8 per 1,000 live births, compared to the all-state median of 6.3. Tennessee also ranks low for dental care – 18 percent of Tennessee adults between 18 and 64 have lost six or more teeth because of tooth decay, infection or gum disease, placing the state at the 49th spot for that indicator.

"The way we've paid for care, whether it's the private sector or the public sector, we've been willing to pay for care when people get really sick," said Schoen. But she hopes that studies like this one will serve as a call to action to encourage health care leaders to think about incentivizing preventive care. "There are some signs that as we pay differently for care, we can encourage care systems to innovate."

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