AIMING HIGHER FOR HEALTH SYSTEM PERFORMANCE A Profile of Seven States That Perform Well on the Commonwealth Fund’s 2009 State Scorecard: Overview OCTOBER 2009 T h e C o m m o n w e a lt h F u n d The Commonwealth Fund, among the first private foundations including low-income people, the uninsured, minority Americans, started by a woman philanthropist—Anna M. Harkness—was estab- young children, and elderly adults. The Fund carries out this mandate by supporting independent lished in 1918 with the broad charge to enhance the common good. research on health care issues and making grants to improve health The mission of The Commonwealth Fund is to promote a high care practice and policy. An international program in health policy is performing health care system that achieves better access, improved designed to stimulate innovative policies and practices in the United quality, and greater efficiency, particularly for society’s most vulnerable, States and other industrialized countries. Aiming Higher for Health System Performance: A Profile of Seven States That Perform Well on the Commonwealth Fund’s 2009 State Scorecard: Overview G reg M oody and S haron S ilow -C arroll H ealth M anagement A ssociates O ctober 2009 To download the complete report containing all seven state profiles, click here. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become avail- able, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1329. Overview in order to realize greater value and greater gains in The 2009 edition of The Commonwealth Fund’s outcomes. The goal of this report is to showcase State Scorecard on Health System Performance identi- insights from high-performing states and identify fies wide variation across states in numerous indica- opportunities for all states to pursue policies and tors related to access, quality, avoidable hospital use practices that may be reasonably associated with and costs, and healthy lives. State Scorecard findings high performance. suggest that if middle- and low-performing states were to implement strategies and policies to help Affordable Coverage for All bring them to the levels of the highest-performing The seven states profiled in this report have a long states, significant cost savings and improved health history of health system improvement focused on outcomes could be achieved. expanding health insurance coverage for uninsured As a companion to the 2009 State Scorecard, this residents. Most experts in these states credit health report profiles seven state health systems: six that reforms enacted in the early 1990s as setting the rank among the top quartile of states—Vermont, stage for recent coverage expansions and quality Hawaii, Iowa, Minnesota, Massachusetts, and gains. All seven profiled states, for example, made Wisconsin—plus Delaware, which was one of the significant, early gains in coverage by extending most-improved states (achieving improvement of 5 Medicaid benefits to otherwise uninsured residents. percent or greater on at least half the scorecard’s indi- The authority for these expansions was granted by cators) from 2007 to 2009. The six leading states the federal government through Medicaid 1115 dem- also improved substantially since the 2007 State onstration waivers and, in most cases, included sig- Scorecard on many indicators of performance. nificant federal financial support. In general, the states that ranked in the top Health system improvement does not come all at quartile in the 2007 State Scorecard remain the lead- once, but is accumulated over years, sometimes ers in 2009, outperforming their peers on multiple decades, one layer of success building on another. indicators (Table 1).1 These patterns and the findings States that want to replicate Massachusetts’ precedent from the state profiles indicate that public policies setting 2006 reforms, for example, must first under- plus state and local health care systems can make a stand that earlier reforms in 1985, 1988, 1991, difference. Vermont and Massachusetts, for example, 1996, and 1997 were necessary to put the 2006 have enacted comprehensive reforms to expand cov- reforms within reach. Change on this scale requires erage and put in place initiatives to improve popula- persistent focus: the complexities of health care and tion health and benchmark providers on quality. its many dysfunctions, say the veterans of reform, Minnesota is a leader in bringing public- and private- require ongoing and comprehensive solutions to sector stakeholders together in collaborative initia- expand access, improve quality, and control costs. tives to improve the overall value of health care—an Shared Values Drive Collaboration approach that is gaining traction in other states. Policymakers in the seven profiled states credit their The challenge for all states and for all private-sec- states’ “culture of collaboration” as the critical driver tor health care delivery systems is to learn to use in health system performance. “We trust each other,” health care resources more effectively and efficiently, 4 they say, or “We work through our differences to do electronically, and experimenting with payment what is right.” In some states, this process is well- reforms that reward health professionals for the qual- organized, like Vermont’s Blueprint for Health. In ity rather than the quantity of services provided. others, like Minnesota, change emerges dynamically from “coalitions of coalitions.” But leaders in all of Aiming Higher: A Congruent Set of Policies the high-performing states are quick to name the States with high-performing health systems work values that set the terms of collaboration—a progres- hard to establish a congruent set of policies that sive political tradition in Massachusetts, a commit- make the most of both state and federal resources. ment to public health in Vermont, an agricultural States play many roles in the health system: purchas- work ethic in Iowa, and in Delaware it is simply ers of coverage for vulnerable populations and their “The Delaware Way.” employees; regulators of providers and insurers; advo- cates for public health; and, increasingly, conveners A Firm Foundation of Transparency of and collaborators with other health system stake- and Innovation holders. State action is also key to improving primary States with high-performing health systems have a care infrastructures and community-wide systems number of state policies and practices in common. In that facilitate access, improve coordination, and pro- addition to expanding coverage, recent health mote effective care. reforms in the profiled states have focused on increas- The seven states profiled in this report show that ing value by improving quality and controlling costs. very high levels of health system performance are The most important strategy has been to make achievable and sustainable. Vermont, Hawaii, Iowa, health information transparent to consumers and Minnesota, Massachusetts, Wisconsin, and Delaware purchasers. The State Scorecard documents wide- provide useful and interesting examples of state poli- spread improvement on selected indicators, especially cies and practices that may be reasonably associated quality indicators for which there has been a national with health system improvement. Across these states, commitment to reporting performance data and col- there are common strategies that others may con- laborative efforts to improve. sider: a long-term commitment to reform, encourag- Most of the profiled states support a stand-alone ing collaboration among multiple stakeholders, lead- organization with a specific mission to collect and ership to expand health insurance coverage through publicly report cost and quality information.2 In public programs, transparency of health information, many cases, these organizations were established by and making sure the state has the capacity to recog- physician leaders or hospital systems to improve nize and act on emerging best practices. patient care and today function as a multi-stake- Delivery system characteristics also may play a holder forum to align statewide quality improvement role in supporting an infrastructure of improvement and cost control initiatives. These organizations are in higher-performing states. The seven states tend to “on call” to evaluate and adopt emerging best prac- have a greater proportion of hospitals that are part of tices, and have put the profiled states among the integrated systems, and their community hospitals nation’s leaders in establishing patient-centered medi- are predominantly nonprofit or government-owned cal homes, exchanging health information (Table 2). Health plan enrollment tends to be more 5 Table 1. State Scorecard Results: High Performing and Most-Improved Statesa PERFORMANCE SUMMARY Overall Scorecard Rank Number of Indicators in Top Quartile Number of Indicators in Top 5 States Number of Indicators Improved by 5% or More PERFORMANCE ON SCORECARD INDICATORS Access Nonelderly adults (ages 18–64) insured Children (ages 0–17) insured At-risk adults visited a doctor for routine checkup in the past two years Adults without a time in the past year when they needed to see a doctor but could not because of cost Prevention and Treatment Adults age 50 and older received recommended screening and preventive care Adult diabetics received recommended preventive care Children ages 19–35 months received all recommended doses of five key vaccines Children with both a medical and dental preventive care visit in the past year Children who received needed mental health care in the past year Hospitalized patients received recommended care for heart attack, heart failure, and pneumonia Surgical patients received appropriate care to prevent complications Home health patients who get better at walking or moving around Adults with a usual source of care Children with a medical home Heart failure patients given written instructions at discharge Medicare patients whose health care provider always listens, explains, shows respect, and spends enough time with them Medicare patients giving a best rating for health care received in the past year High-risk nursing home residents with pressure sores Long-stay nursing home residents who were physically restrained Long-stay nursing home residents who have moderate to severe pain Avoidable Use and Cost Hospital admissions for pediatric asthma per 100,000 children Adult asthmatics with an emergency room or urgent care visit in the past year Medicare hospital admissions for ambulatory care sensitive conditions per 100,000 beneficiaries Medicare 30-day hospital readmissions as a percent of admissions Long-stay nursing home residents with a hospital admission Short-stay nursing home residents with hospital readmission within 30 days Home health patients with a hospital admission Hospital Care Intensity Index (US=1.0 in 2001)b Total single premium per enrolled employee at private-sector establishments that offer health insurance Total Medicare (Parts A & B) reimbursements per enrollee 6 Vermont Hawaii Iowa Minnesota Massachusetts Wisconsin Delaware 1 2 2 4 7 10 14 22 22 21 25 14 15 13 8 14 11 11 11 5 8 14 15 14 15 14 14 17 US Vermont Hawaii Iowa Minnesota Massachusetts Wisconsin Delaware Rate Rate Rank Rate Rank Rate Rank Rate Rank Rate Rank Rate Rank Rate Rank 80.0 86.5 10 89.4 2 87.2 6 89.2 3 92.8 1 88.1 4 85.7 12 89.6 93.4 15 94.9 4 95.0 2 93.5 13 96.8 1 94.2 11 91.7 22 84.6 84.4 25 84.0 27 85.6 20 88.7 6 91.3 3 84.8 22 91.8 2 86.6 89.9 16 93.1 1 92.2 4 90.9 7 92.7 2 91.5 5 90.7 9 42.3 49.3 8 41.4 28 42.9 23 50.8 3 49.5 7 45.3 16 52.5 1 44.3 55.3 2 49.3 10 48.7 12 66.9 1 na na 54.3 4 49.0 11 80.1 79.8 30 87.8 4 80.0 27 84.7 7 83.9 8 79.4 32 81.8 13 71.6 79.4 7 80.3 6 75.4 13 67.5 38 82.6 2 68.2 35 72.7 20 60.0 69.3 13 62.8 28 74.5 5 67.0 17 66.6 19 61.4 34 76.9 3 91.3 94.5 6 87.5 50 94.9 4 93.3 14 91.8 25 93.6 9 92.4 21 84.6 91.0 3 78.3 51 86.8 20 88.2 12 90.3 6 90.2 7 87.0 17 40.3 38.8 35 40.5 26 34.8 48 33.8 50 40.9 23 37.9 41 37.3 44 79.7 86.8 6 85.9 8 84.6 12 78.1 34 88.5 4 85.2 10 89.0 1 57.5 67.2 3 60.1 27 66.9 4 63.0 14 66.2 5 62.9 16 59.9 28 74.7 82.3 7 65.4 48 81.6 8 76.6 21 75.1 26 76.2 23 84.2 5 na `74.5 24 77.4 4 74.5 24 77.4 4 75.1 13 75.1 13 78.0 1 na 61.5 21 66.0 6 67.6 3 66.4 4 62.5 17 65.0 9 69.3 1 12.0 9.4 11 7.6 3 8.0 5 7.7 4 10.9 22 10.1 16 12.3 37 5.1 2.4 15 2.9 19 1.8 5 2.3 14 4.7 32 1.8 5 1.5 1 4.4 3.6 14 2.2 3 4.7 30 3.6 14 2.5 4 3.9 19 4.0 21 164.9 50.2 2 81.0 4 81.0 4 102.2 9 125.5 18 109.1 12 na na 17.6 12.4 5 13.1 8 12.3 4 12.6 7 13.7 10 14.5 11 21.6 33 6,587 4,963 12 4,144 3 5,981 20 4,749 8 7,262 39 5,872 18 5,427 15 18.4 14.4 6 16.6 15 15.9 10 16.6 15 19.4 37 16.2 12 20.6 45 19.9 11.3 6 na na 16.7 21 6.9 1 14.8 17 13.8 12 19.6 27 21.2 14.3 2 na na 18.3 17 17.6 14 19.5 21 17.7 15 23.0 39 31.9 30.0 31 23.5 6 36.1 45 32.7 37 34.1 40 27.7 20 27.3 19 1.020 0.652 9 1.051 39 0.753 17 0.697 10 0.962 27 0.719 12 1.091 41 $4,386 $4,900 47 $3,831 2 $4,146 14 $4,432 31 $4,836 44 $4,777 42 $4,733 40 $8,304 $7,284 17 $5,311 1 $6,572 7 $6,600 9 $9,379 47 $6,978 15 $7,646 25 7 Table 1. State Scorecard Results: High Performing and Most-Improved Statesa (continued) PERFORMANCE ON SCORECARD INDICATORS Healthy Lives Mortality amenable to health care, deaths per 100,000 population Infant mortality, deaths per 1,000 live births Breast cancer deaths per 100,000 female population Colorectal cancer deaths per 100,000 population Suicide deaths per 100,000 population Nonelderly adults (ages 18–64) limited in any activities because of physical, mental, or emotional problems Adults who smoke Children ages 10–17 who are overweight or obese a States are shown in order of their ranking on the 2009 State Scorecard. Delaware is an example of a state with the most improved performance. b Based on inpatient days and inpatient visits among chronically ill Medicare beneficiaries in last two years of life. na=not applicable, data value is missing. Notes: All rates are expressed as percentages unless labeled otherwise. See Appendix B in the State Scorecard Report for data year, source, and definition of each indicator. Source: Commonwealth Fund 2009 State Scorecard on Health System Performance Table 2. A Snapshot of States with High Performing Health Systems* Demographics Resident population in millions, 2008 (a) Median household income, 2005–2007 Percent of population with income below 200% of federal poverty level, 2006–2007 Health Status Cancer incidence, age-adjusted rate per 100,000, 2004 Percent of adults who are overweight or obese, 2008 Adult self-reported current asthma prevalence rate, 2007 Percent of adults ever told by a doctor that they have diabetes, 2008 Delivery System Characteristics Percent of community hospitals that are part of highly integrated systems, 2008 (b) Percent of community hospitals that are nonprofit or owned by state/local government, 2007 (d) Market share of top two insurers (percent of commercial HMO/PPO members), 2006 (c) *States are shown in order of their ranking on the Commonwealth Fund State Scorecard on Health System Performance, 2009. Delaware is an example of a state with the most improved performance. (a) US Census Bureau Resident Population, July 2008: http://www.census.gov/compendia/statab/ranks/rank01.html. (b) SDI data reported in the Sanofi Aventis Managed Care Digest Series, Hospital/Systems Digest, 2009. Highly integrated systems either own or contract with three or more components of health care delivery including at least one acute-care hospital, at least one physician component, and at least one other component such as a health maintenance organization (HMO), nursing home, home health agency, or surgery center. They also have at least one systemwide contract with a tpayer (e.g., employer, HMO or government entity). Hospitals include short-term, acute-care, nonfederal hospitals in the SDI database. (c) American Medical Association, Competition in Health Insurance: A comprehensive study of U.S. markets, 2008 update. For states with missing data in 2006, alternate years were utilized to create rankings. Data for Delaware and Wisconsin from 2005. Rankings based on 48 states with available data. US total based on American Medical Association, Competition in Health Insurance, 2007. These data were corrected and updated as of February 22, 2010. (d) Kaiser State Health Facts: http://statehealthfacts.org/comparebar.jsp?ind=383&cat=8. Community hospitals include nonfederal, short-term general and specialty hospitals whose facilities and services are available to the public. Excludes long term care hospitals, psychiatric hospitals, institutions for the mentally retarded, and alcoholism and other chemical dependency hospitals. All other data from The Commonwealth Fund State Scorecard for Health System Performance, 2009, Exhibit A16. 8 US Vermont Hawaii Iowa Minnesota Massachusetts Wisconsin Delaware Rate Rate Rank Rate Rank Rate Rank Rate Rank Rate Rank Rate Rank Rate Rank 95.6 68.0 3 79.8 19 79.1 18 63.9 1 78.0 17 77.7 15 96.7 30 6.9 6.5 19 6.6 23 5.4 8 5.1 2 5.1 2 6.5 19 9.0 46 24.1 20.4 4 19.0 2 21.1 6 22.4 12 23.2 20 22.6 15 23.6 24 17.5 17.6 22 14.5 3 18.2 29 14.8 4 17.6 22 16.3 11 17.9 27 10.9 12.2 28 8.3 7 10.9 16 10.3 12 7.2 5 11.5 22 9.6 11 16.9 17.2 28 12.9 2 14.1 3 15.0 11 16.1 20 14.2 5 18.9 38 19.4 17.7 12 17.2 6 20.6 33 17.4 8 17.0 5 20.1 26 20.3 29 31.7 26.8 9 28.5 15 26.5 8 23.1 1 30.1 22 27.9 12 33.1 35 US Vermont Hawaii Iowa Minnesota Massachusetts Wisconsin Delaware* Amount Amount Rank Amount Rank Amount Rank Amount Rank Amount Rank Amount Rank Amount Rank 304.1 0.6 49 1.3 42 3.0 30 5.2 21 6.5 14 5.6 20 0.9 45 $49,901 $51,566 17 $63,164 4 $49,262 24 $57,815 8 $58,286 7 $50,619 19 $54,310 14 35.8 29.2 9 33.4 24 29.4 10 27.7 4 31.1 14 29.9 12 31.5 17 458.2 477.3 36 423.6 4 467.0 31 490.5 43 501.7 48 443.1 10 487.5 41 63.0 58.4 6 57.3 3 64.2 33 62.7 23 58.0 4 63.5 28 63.6 30 8.2 9.6 46 8.0 17 7.0 5 7.7 11 9.9 48 9.2 39 7.8 13 8.2 6.4 4 8.2 25 7.0 11 5.9 1 7.1 13 7.2 14 8.2 25 38.0 46.7 14 22.7 43 28.8 41 47.8 13 46.3 15 59.5 5 50.0 9 82.2 100.0 1 100.0 1 100.0 1 100.0 1 89.7 21 96.0 13 100.0 1 36 74 13 99 1 89 5 85 7 72 16 62 31 65 27 9 concentrated among top plans in the seven states in seeking to enact comprehensive reform. These his- and, while this may limit competition, it also may toric and geographic disparities across states point to facilitate efforts to develop coordinated strategies for the importance of federal action to raise the floor improvement. across all states and create a supportive climate for While leading states such as Massachusetts, state innovation and achievement. Encouraging the Minnesota, and Vermont have enacted policy reforms adoption of systemic improvements will likely require that are extending coverage, promoting community Medicare’s participation in state payment initiatives health, and building value-based purchasing strate- and will require collaborative federal and state efforts gies through public–private collaboration, this has to develop the information and shared resources not been the case in the vast majority of states. In infrastructure necessary to achieve high performance. addition to their willingness to persevere in pursuing The State Scorecard shows that all states can aim reforms, some high-performing states may be advan- higher in their health system performance. With ris- taged by greater resources to support their efforts. A ing costs putting pressure on families and businesses few of the seven profiled states have higher median alike, it is urgent that states and the federal govern- incomes and lower poverty levels than the national ment join together to take action to enhance value in average, while others are closer to the national aver- the health care system and ensure that everyone has age (Table 2). Health status exhibits a somewhat the opportunity to participate in it fully. Improving mixed picture of higher and lower rates of reported the performance of all states to the levels achieved by disease prevalence or risk factors both within and the best states could save thousands of lives, improve across the states profiled. access and quality of life for millions of people, and Lower-performing states, especially states in the reduce costs. In turn, this would free up funds to pay bottom quartile, are often challenged by higher rates for improved care and expanded insurance cover- of disease and poverty, plus high uninsured rates age—producing a net gain in value from a higher- reflecting historic patterns of low employment-based performing health care system. health benefits. Where a large proportion of the pop- ulation is uninsured, states face a much higher hurdle 10