What Providers are do­ing in cer­tain mar­kets to make them the envy of the in­dus­try

Modern Healthcare - - FRONT PAGE - Mau­reen Mckin­ney

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.

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