WHERE YOU WANT TO GET SICK
What Providers are doing in certain markets to make them the envy of the industry
If you call St. Paul, Minn., your home, chances are good that you have better access to preventive care, lower rates of avoidable hospitalizations and fewer complications resulting from treatment than someone who lives in Monroe, La. That’s according to a March 14 report from the Commonwealth Fund, which ranked health system performance in 306 hospital referral regions across the U.S.
“Where you live in this country largely determines, for better or worse, the kind of healthcare you will receive,” Karen Davis, president of the New Yorkbased not-for-profit, said in a news release. “The wide differences in how well the healthcare system performs in the top- and bottom-performing communities reveal many missed opportunities.”
Those missed opportunities, whether due to gaps in quality, overpriced care or poor population health, contribute to worse health outcomes and billions in additional healthcare costs, the authors said. The report found that if all regions performed at the level of those at the top, 9.4 million adults would receive preventive care, and the nation’s healthcare system would save more than $8 billion from avoidable hospital admissions and readmissions.
Commonwealth Fund officials say they timed the release of the report, which draws on data from 2008, 2009 and 2010, to serve as a baseline before many of the provisions of the healthcare reform law take effect. They also said many of the report’s findings regarding uneven access to care, high mortality rates and skyrocketing costs illustrate the need for the law.
But the reasons some regions succeed and others falter are complex, according to providers and health officials on both ends of the spectrum, and that could hinder the reform law’s efforts to address the differences. Those in highperforming communities attribute much of their success to long-standing cultural dispositions, while their peers in lower-performing areas point to challenges such as widespread poverty.
Using 43 metrics, including percentage of insured adults, 30-day mortality for heart failure and percentage of adults who smoke, researchers evaluated access, cost, prevention and other factors across communities. They relied on data from a number of sources, including the CMS’ Hospital Compare, the U.S. Census, the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveil- lance System and the National Vital Statistics System.
The report, Rising to the Challenge: Results from a Scorecard on Local Health System Performance, is the first from the Commonwealth Fund to examine healthcare at the community level. The findings, however, echo its earlier national scorecards, released in 2006, 2008 and 2011, as well as state-by-state scorecards, released in 2007 and 2009, which pointed to gaps in performance from one area of the country to another.
There were enormous differences—sometimes two- and three-fold—across measures, said Cathy Schoen, the Commonwealth Fund’s senior vice president for research and evaluation, a co-author of the report. For instance, she said, on an indicator of potentially preventable mortality before age 75, the top hospital referral region had a rate of 51.5 deaths per 100,000, while the worst-performing region’s rate was 169 per 100,000.
“We ought to have been able to postpone or avoid many of those deaths with more timely and effective care,” said Schoen, who called the results disturbing.
On a diabetes management metric, there was a difference of 27 percentage points between Covington and Lexington—61% vs. 34%— despite the fact that the two Kentucky communities are only about 80 miles apart. The incidence of unsafe medication prescribing was 11% in the New York communities of the Bronx and White Plains, but it was 44% in Alexandria, La.
Variations in healthcare spending were significant, too. Private insurance spending per person in 2009 was $2,014 in Honolulu and $2,228 in Rochester, N.Y., but that amount jumped to $5,068 in Charleston, Va.
Top-performing communities across all indicators tended to be clustered in the Upper Midwest and the Northeast, the report found, while those at the bottom tended to be located in the South. Of the 30 regions that made up the top 10% of local areas overall, four were in Minnesota, four more were in Iowa, and three were in Wisconsin. Seven Louisiana communities made the list of bottom performers, as did six regions from both Mississippi and Texas.
“I’m not surprised at all that Minnesota cities did so well,” said Edward Ehlinger, commissioner of the Minnesota Department of Health. “There’s a long history in this state of working as a community for the health of everyone.”
The state has been far ahead of the curve in quality-improvement efforts, public-private collaboration and community health, Ehlinger added, pointing to the work of organizations such as the Minnesota Alliance for Patient Safety and the Bloomington-based Institute for Clinical Systems Improvement.
“We have a long-standing culture around healthcare improvement,” said Jim Chase, pres-
ident of Minnesota Community Measurement, a regional healthcare improvement organization in Minneapolis. Chase said he credits much of the high performance across the state to preventive care and an infrastructure that encourages care coordination and patient-centeredness.
Many of the results in the Commonwealth Fund’s report paralleled those in a state scorecard released recently by the Iowa Hospital Association, said Perry Meyer, the IHA’S senior vice president. The state scorecard, which the association based on the Institute for Healthcare Improvement’s Triple Aim of critical objectives, which focus on cost, quality and population health, Meyer said. “We’ve known for a long time that Iowa hospitals look very cost-efficient compared to peers around the country,” he said. “And we’ve always ranked in the top quartile to top 10% on measures from Hospital Compare.”
Healthcare is practiced very conservatively in Iowa, Meyer said, and the state has a well-established system of public reporting, transparency and collaborative learning. In December, HHS designated the IHA as one of 26 hospital engagement networks, organizations that will work to identify and disseminate evidencebased best practices as part of the government’s Partnership for Patients initiative.
But even high-performing communities have room for improvement, the Commonwealth Fund said, noting that no region excelled on all 43 indicators. In Minnesota, many rural communities are underresourced and need better access to primary care, Ehlinger said. And Iowa has a long way to go toward addressing smoking, obesity, diabetes and other areas of community health, Perry said.
Providers in the lowest-performing communities face myriad obstacles, according to officials from those states. Marcella Mckay, chief operating officer of the Mississippi Hospital Association, says the state has worked hard to improve care for the chronically ill, reduce infant mortality and better coordinate care.
“However, the challenges are complex and greatly complicated by poverty within the general population and constrained financial resources at the federal, state and local levels, making it difficult to tackle the serious health and healthcare problems within the state,” Mckay said in an e-mail.
The Mississippi hospital referral regions analyzed in the report—gulfport, Hattiesburg, Jackson, Meridian and Oxford—were all ranked in the bottom decile overall and they also fared poorly across specific measures of affordability, prevention and other areas.
Louisiana, another state with a large number of poor-performing communities, has its own share of problems, said Cindy Munn, executive director of the Louisiana Health Care Quality Forum, a Baton Rouge-based not-for-profit quality-improvement organization.
“Providers are really bombarded with everchanging regulations,” Munn said. “They are in overload. Also, our state is very rural and there is a shortage of primary-care physicians.”
Still, Munn said, public and private organizations are working hard on quality-improvement efforts targeting diabetes and cardiovascular disease. The LHCQF was also designated by the state to promote the implementation of health information technology through its health information exchange and as a regional extension center.
“It’s discouraging that we’re not moving the dial as fast as we’d like to, but we try to provide the message that all of these initiatives build on one another,” Munn said.
The common thread among low performers is lack of access, said the Commonwealth Fund’s Schoen. The report referred to access to care as “the foundation and hallmark of a high performing health system.” Indeed, the regions that performed well on access metrics—including proportions of adults who said they went without care or who had a dental visit during the last tended to perform very well over
year— all. “When we look at communities that are in the top 10% or top 25%, they have much, much lower rates of uninsured,” she said. “Access is critical.”
The Commonwealth Fund anticipates it will release the next local scorecard in 2015, when Schoen predicts many of the healthcare reform law’s effects will be apparent. Those improvements will hopefully include a “sea change” in access, she said, supported by insurance expansions, increased Medicaid payment rates, better reimbursement rates for primary care, new delivery models such as accountable care organizations, and pilot projects that look at successful interventions tailored for individual regions.
“We don’t want to see any more communities like two in Texas where more than 50% of people are uninsured,” Schoen said.
Poor access to care was identified as a common thread among areas with the lowest performing healthcare systems, such as New Orleans, where a clinic staged at the convention center, above, provided free care to the uninsured.