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'Shocking' difference among states on quality, access, other indicators
Where one lives clearly matters for access to care when it is needed, the quality of care that can be received, and opportunities to lead healthier lives, according to a new state-by-state scorecard issued by the Commonwealth Fund Commission on a High Performance Health System. "The differences we found between the top and bottom states were shocking, often a two- to threefold variation or greater," according to Commonwealth Fund senior vice president for research and evaluation Cathy Schoen, the report's co-author.
Ms. Schoen tells State Health Watch that even though the data she and her colleagues examined have been in the public arena for some time, they were "struck by the incredible variations such as asthma admissions for children and the percentage of people in some states who are uninsured. And we were struck by the levels the highest-performing states have achieved."
The report ranked states on 32 indicators grouped in categories including access, quality, avoidable hospital use and costs, equity, and healthy lives (see Exhibit 1). While no one state scored at the top across the board, some states far surpassed others, the commission said. States in the Northeast and upper Midwest often ranked high in several dimensions, while states in the South tended to have the lowest rankings (see Exhibit 2).
Thirteen states—Hawaii, Iowa, New Hampshire, Vermont, Maine, Rhode Island, Connecticut, Massachusetts, Wisconsin, South Dakota, Minnesota, Nebraska, and North Dakota—emerged in the top quartile of the overall performance rankings. The commission said these states generally ranked high on multiple indicators in each of the five dimensions assessed by the scorecard and many have been leaders in reforming and improving their health systems and have among the lowest uninsured rates in the nation.
At the other end of the spectrum, the 13 states in the bottom quartile of the overall performance ranking—California, Tennessee, Alabama, Georgia, Florida, West Virginia, Kentucky, Louisiana, Nevada, Arkansas, Texas, Mississippi, and Oklahoma—lagged well behind their peers on multiple indicators across dimensions. Uninsured rates for adults and children in these states are well above national averages, and more than double those in the quartile of states with the lowest rates. The rates for receipt of recommended preventive care are generally low, and mortality rates from conditions amenable to health care often high.
Significant progress could be made
The report estimates that if all states could do as well as the top states, 90,000 lives could be saved each year, 22 million additional adults and children would have health insurance, and millions of older adults, diabetics, and young children would receive essential preventive care. Also, the report says, Medicare could save $22 billion a year if high-cost states moved down to spending levels of the average states.
The report, Aiming Higher: Results from a State Scorecard on Health System Performance, compares each state to benchmarks that have already been achieved in some states.
"As policy-makers and private sector leaders look at how their states did on this scorecard, it should be clear that there is room for improvement in all states," said lead author Joel Cantor, director of the Rutgers University Center for State Health Policy. "In key areas, even the top states aren't doing as well as they could be."
Across the country, the scorecard found that states that score well on access to care, particularly through health insurance coverage, were also more likely to do better on quality of care. Four of the five states with the best access to care rankings (Massachusetts, Iowa, Rhode Island, and Maine) also are among the highest on quality of care. And states with low quality rankings tend to have high rates of uninsured residents.
The five top-ranked states overall (Hawaii, Iowa, New Hampshire, Vermont, and Maine) all have high rates of insurance coverage, with nearly 90% of working-age adults insured. In contrast, the share of adults insured ranges between 70% and 78% in the five states with the lowest ranking (Nevada, Arkansas, Texas, Mississippi, and Oklahoma).
"The findings point to improving access to care and health insurance coverage as important first steps toward ensuring that all patients get recommended care that is patient-centered, well coordinated, and efficient," the report says. "In states with low rates of uninsured, adults and children are more likely to receive essential preventive and chronic care and to have an ongoing connection to care."
No connection between spending and quality
Interestingly, the researchers found no systematic connection between high spending and high quality health care. They report that some states achieve high quality at relatively low cost. The states with the highest levels of spending tended to have higher rates of preventable hospital use including readmissions and admissions for diabetes, asthma, and other chronic illnesses that should be effectively treated outside the hospital. "The scorecard documents stark variability across states in potentially preventable use of hospitals," the commission said. "For example, the rate of children admitted to the hospital for asthma ranges from 55 per 100,000 in Vermont to 300 per 100,000 in South Carolina.
The commission said its scorecard "points to the substantial gains for the nation if all states could reach levels achieved by the top-performing states on key indicators." Among the items cited:
"The report points to the need for action in four key areas," the commission said, "expanding health insurance to all; having better information to assess performance to guide and drive change; analyses to determine the key factors that contribute to state variations; and national leadership and collaboration across public and private sectors. In addition, the report underscores opportunities for states to look to each other as well as models of excellence within their own borders to inform efforts to improve."
Action needed at all levels
"The scorecard tells us where we are," said Commonwealth Fund president Karen Davis. "States need healthy and productive citizens. Doing better is possible, but it will take commitment and action on all levels to achieve real change. The state scorecard documents that we have much to gain as a nation with coherent national and state policies that respond to the urgent need for action."
According to the commission, universal health care coverage is critical for improving quality and delivering cost-effective care, as well as ensuring access. Federal action as well as state initiatives will be essential for progress nationwide.
Also needed, it said, is more information to assess performance and identify benchmarks. "It takes information to guide and drive change," the report said. "We need more sophisticated information systems and better information on practices and policies that contribute to high or varying performance.
The commission said there is a need for analyses to determine key factors that contribute to variations, noting states can use such information to develop evidence-based strategies for improvement.
Finally, it said, national leadership and collaboration across public and private sectors is essential for coherent, strategic, and ultimately effective improvement efforts.
Ms. Schoen tells State Health Watch the researchers were struck by the association between rankings on access to health care and those on quality. She said there was a fairly consistent correlation with hospital process quality indicators that the researchers would not have intuitively expected to be present.
Asked whether the problem is too big to be resolved by states on their own, Ms. Schoen says there are things states can do in terms of state policy and health system practices such as benchmarking. There are some aspects, she said, however, where it will be necessary to look at federal solutions or federal support for state solutions. She noted that in recent years, states have expanded insurance coverage when the federal government helped with Medicaid and SCHIP expansions.
"If the federal government acted," she said, "it would support states in moving forward. Many states are waiting in the wings to develop a comprehensive plan."
Focus on improvement
Ms. Schoen says the commission hoped the scorecard would draw attention to the opportunity to improve and stimulate action and so far it has received positive attention. State officials who have contacted her, she says, have asked for statewide leadership forums where ideas could be exchanged. Officials, she said, have identified the scorecard dimensions where they are doing well but could do better and the areas where they are not doing well and could improve.
Ms. Schoen says that in many ways expansion of insurance coverage is the key to success on this issue. "It's not sufficient to aim higher across cost and quality," she said. "We often think of health care in a fragmented way without total coverage. According to Ms. Schoen, churning and fragmentation of the insurance market make it hard to benchmark and give health plans an incentive to put systems in place for the long haul. Insurance, she says, is a foundation to address quality and benchmarks in a new light.
Having now issued a national scorecard and a state scorecard, the commission will move over the next several years from descriptive reports to modeling and options to be considered.
Commenting on the scorecard, Ms. Davis discussed the experiences of Hawaii and Maine in extending health insurance to all. She says Hawaii's ranking in first place overall may be due in part to its early efforts to cover its residents. In 1974, the state's Prepaid Health Care Act mandated that employers, with a few exceptions such as seasonal employers and government services, provide insurance to all employees working more than 20 hours a week. Employers must pay 50% of premiums, but can require employees to contribute up to 1.5% of their wages. Other residents, including employees working fewer than 20 hours per week, the self-employed, and Medicaid beneficiaries receive coverage under a public program called the State Health Insurance Plan. The legislation also mandates that insurance plans offer certain benefits, including hospital and surgical benefits, maternity benefits, and laboratory services.
Ms. Davis says Maine's Medicaid program has been expanded to cover all adults below 100% of the federal poverty level and parents below 200% of the federal poverty level. In addition, Maine's reform legislation created a new insurance product, DirigoChoice, with a maximum deductible of $1,250 and lower sliding-scale deductibles and premiums available to residents with incomes below 300% of the federal poverty level. Employers who don't cover workers may voluntarily pay a fee covering 60% of the workers' premiums for DirigoChoice.
Ms. Davis also gave examples of New York and Rhode Island promoting effective cost control strategies; Iowa and Connecticut organizing the health care system; North Carolina and South Carolina pursuing and raising benchmark levels of high-quality, safe, effective, and efficient care and enhancing system capacity to innovate and improve; and Wisconsin and Kansas sharing a coherent set of health policies through national leadership and public-private collaboration.
At a news conference at which the scorecard was released, University of North Dakota School of Medicine and Health Sciences associate dean Mary Wakefield cautioned that policies and strategies directed to just one of the scorecard areas such as efficiency or high quality and safety are not going to get the nation to a high-performing health care system. "So when we think about policy changes and strategies and approaches," she said, "it is a set of strategies that addresses all four of those areas. That is a big menu, a big portfolio of activity to put in front of state policy-makers, clinicians, researchers, federal policy-makers, and so on, but it is that complement of activities in areas of focus that the commission thinks are necessitated or is necessitated for us to create a high-performance health system in this country. So we need efforts in each of those areas to support moving the set of scorecard measures north on the metrics instead of south on the scale."
The report is available on-line from www.cmwf.org. Contact Ms. Schoen and Ms. Davis at (212) 606-3864. Contact Ms. Wakefield at (701) 777-3848 and Mr. Cantor at (732) 932-4653.