CASE STUDY JULY 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care Sarah Klein Martha Hostetter Douglas McCarthy Consulting Writer and Editor The Commonwealth Fund Consulting Writer and Editor The Commonwealth Fund Senior Research Director The Commonwealth Fund PADUCAH ILLINOIS PROFILE KENTUCKY TENNESSEE The hospital referral region encompassing Paducah and HEALTH SYSTEM PERFORMANCE Improved on its neighboring counties, most in rural Western Kentucky, 17 OF 32 distinguished itself as one of only a handful of U.S. regions indicators tracked over time to improve on a majority of measures tracked by the HEALTH SYSTEM RANK Commonwealth Fund’s Scorecard on Local Health System 225 279 Performance, 2016 Edition. The most striking gains were tied OF vs. OF to the state’s Medicaid expansion, which added nearly 500,000 306 306 regions in 2016 regions in 2012 low-income adults to the program. Local leaders who were concerned about lack of access to care relied on the expansion DEMOGRAPHICS (2014) to recruit federally qualified health centers to the region, while 359,866 $44,171 hospitals and other providers enhanced access through school- median across 27 counties household income based clinics, which offer urgent and behavioral health services. 88% white (vs. $58,489 nationally) (vs. 62% nationally) 7% black (vs. 12% nationally) 3% other 38% living on incomes KEY TAKEAWAYS non-Hispanic below 200% (vs. 8% nationally) Kentucky’s Medicaid The expansion also Nascent efforts to of the federal expansion fueled galvanized local address population 3% Hispanic poverty level (vs. 17% nationally) (vs. 34% nationally) dramatic reductions efforts to establish health challenges Note: Race/ethnicity data may not sum to 100% because of rounding. in the uninsured rate. federally qualified will take longer to Source: D. Radley, D. McCarthy, and S. L. Hayes, Rising to the Challenge: The Commonwealth Fund Scorecard on Local Health System Performance, health centers. yield results. 2016 Edition, The Commonwealth Fund, July 2016; American Community Survey, 2014 1-year estimates, www.factfinder.census.gov. How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 2 BACKGROUND The Paducah region was one of only a handful in the United States to distinguish itself for improving on a Paducah has a history of reimagining itself. Nearly 20 majority of indicators tracked by the Commonwealth years ago, this small city at the hub of the nation’s inland Fund’s Scorecard on Local Health System Performance, 2016 waterways on Kentucky’s westernmost border joined Edition. In comparing the performance of 306 regional a vanguard of U.S. communities that used the arts as an markets for medical care, known as hospital referral economic engine by offering artists from around the world regions (HRRs), the Scorecard found wide variation on incentives to purchase and restore dilapidated housing. In indicators of health care access, quality, avoidable hospital what has become the Lower Town Arts District now stand use, costs, and outcomes across the U.S. the National Quilt Museum, an 1,800-seat performing arts venue, art galleries, restaurants, and retail shops. This The Paducah HRR improved on 17 of 32 performance renaissance helped Paducah, a town of just 25,000, garner measures—elevating its rank from 279th nationally to the fifth-place spot in National Geographic’s 2014 list of 225th. This profile is part of a case study series that seeks to World’s Smart Cities. understand the drivers of performance on the Scorecard, especially in communities facing socioeconomic Murals on the city’s flood barrier commemorate other challenges. Since the Paducah region was a standout in pivotal moments in Paducah’s history, including a Civil improving access to care, this case study focuses on the War–era battle that forced the demolition of the Lower access dimension and the community’s response to the Town district and a 1937 flood that forced residents to flee. Affordable Care Act. They also celebrate the ways Paducah has capitalized on its geography with industries built around transportation rather than coal, the decline of which produced economic A STRONGER ECONOMY THAN OTHER PARTS and social challenges in other parts of the state. OF THE STATE The Paducah region’s economy revolves around agriculture, professional services, barge companies that ferry goods up the nearby Mississippi, and businesses like Computer Services Inc., which develops the technology banks and financial institutions need to process transactions. “Our economy has a history of being very stable—it doesn’t swing wildly from one extreme to another,” says John Williams, Sr., who founded Computer Services in 1965. Murals along Paducah’s floodwall capture the city’s storied history. commonwealthfund.org Case Study, July 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 3 Paducah, Kentucky Hospital Referral Region Local Scorecard Performance Ranking Summary Change in Performancea (of 306 Local Areas) Quintile Rank Average of HRRs Paducah in the U.S. 2012* 2016 2012* 2016 Count Percent Count Percent OVERALL 5 4 279 225 Indicators Access & with trends 32 33 4 2 203 109 Affordability Prevention & Area rate improved 17 53% 11 33% 5 4 266 229 Treatment Area rate Avoidable Hospital worsened 2   6% 3   9% 5 5 277 286 Use  & Cost Little or no change Healthy Lives 5 4 259 215 in area rate 13 41% 19 58% Note: The Paducah hospital referral region (HRR) also includes parts of Illinois and Tennessee. * Rankings from the 2012 edition of the Local Scorecard have been revised to match methodology and measure definitions used in the 2016 edition. a Improved or worsened denotes a change of at least one-half (0.5) of a standard deviation (a statistical measure of variation) larger than the indicator’s distribution among all HRRs over the two time points. Little or no change denotes no change in rate or a change of less than one-half of a standard deviation. For complete results, visit the Health System Data Center. Source: D. Radley, D. McCarthy, and S. L. Hayes, Rising to the Challenge: The Commonwealth Fund Scorecard on Local Health System Performance, 2016 Edition, The Commonwealth Fund, July 2016. The area is not without its challenges, however. Though During this period, the Paducah area outpaced the state not beset with the opioid epidemic that plagues Eastern on other measures of access. Most notably it achieved Kentucky, regional rates of obesity, suicide, and smoking among the greatest declines nationally in the percentage (even among pregnant women) are high. Poverty is also of adults who went without care because of cost (from a concern. When Williams observed that the number 20% to 13%) and at-risk adults who went without a routine of children qualifying for free lunches was steadily medical visit in the past two years (from 17% to 13%). increasing, he joined other community leaders in forming the Impact Poverty Task Force in 2010. Operating under NEW COVERAGE LEADS TO NEW CLINICS the aegis of the United Way of Paducah-McCracken Kentucky’s Medicaid expansion, initiated by former County, the task force seeks to address the underlying Democratic Gov. Steve Beshear in 2014, added close to causes of poverty. One early finding was that poor 500,000 adults to the rolls in a state of roughly 4.4 million.2 residents lacked access to medical care. By the end of 2015, the uninsured rate for adults ages 19 That has changed with the state’s Medicaid expansion, to 64 in the Paducah region had fallen to 7.8 percent, just which tripled the number of adults enrolled statewide.1 below the statewide rate of 8.2 percent—both historic lows. With that and other coverage provisions introduced by The Medicaid expansion galvanized efforts to establish the Affordable Care Act, the percentage of uninsured federally qualified health centers (FQHCs) in the region, adults in the HRR encompassing Paducah declined from helping to address longstanding shortages of primary 20 percent in 2012 to 12 percent in 2014, according to care providers that have been particularly acute in the the Scorecard. Paducah was among the most improved poorer counties that run alongside the Mississippi River. regions in the U.S. on this measure—one of 32 regions “Previously, we had struggled to get any of the federally where the uninsured rate dropped by 8 percentage points qualified health center networks in Kentucky to come this or more. (Kentucky as a whole experienced the greatest far over from the capitol,” says Brandi Harless, who was reduction of any state in the nation.) elected Paducah’s mayor in November 2016. commonwealthfund.org Case Study, July 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 4 Before the Affordable Care Act, the St. Nicholas Family Clinic, a free clinic in Paducah that Harless previously ran, had attempted to fill the gap, relying on a roster of volunteer doctors and nurses and grants from local hospitals to provide medical care to the working poor. With Medicaid expansion on the horizon, clinic and civic leaders reached out to ARCare, an Arkansas-based FQHC operator. The nonprofit had already crossed state lines in 2012 to establish a health center in Bardwell, Kentucky, some 30 miles southwest of Paducah, at the behest of that county’s top elected official. Brandi Harless, Paducah’s mayor, helped bring a federally qualified The free clinic offered its space to the nonprofit, which health center to the city. operates under the banner KentuckyCare, as well as a stipend to cover care for its patients until they could enroll in the Medicaid program. “Had St. Nicholas not been The expansion of coverage and the additional support willing to recruit us, it might have taken us longer to get for FQHCs provided by the Affordable Care Act also here,” says Emerson Goodwin, KentuckyCare’s corporate encouraged already established health clinics in the regional director. Since 2012, KentuckyCare has opened area to expand, says David Bolt, deputy director of the five clinics in Western Kentucky, including a second clinic Kentucky Primary Care Association, which negotiates in Paducah. insurance contracts for its members, including FQHCs and Staffed by physicians and nurse practitioners, rural clinics. One was the Pennyroyal Center, a community KentuckyCare now serves roughly 20,000 patients, 60 mental health center, which helped launch an FQHC in percent of whom are covered by Medicaid, up from Princeton, Ky., in 2013. Health First Community Health 30 percent in 2012. In Paducah, it quickly outgrew the Center, which was launched in 2010, opened another clinic St. Nicholas Family Clinic’s space and moved to a new early in 2016. building with twice as many exam rooms, a drive-thru The Medicaid expansion has changed the operations of pharmacy, and the latest in X-ray equipment. local free clinics, which have historically limited services KentuckyCare is planning to establish family health to residents who are working but lack insurance. In centers serving each of the counties that make up the Calloway County, Angels Community Clinic saw its Jackson Purchase, a region bounded by the Mississippi, patient census drop from 600 a year before the expansion Ohio, and Tennessee Rivers. to 100 after. “The people who really needed Medicaid seem Paducah’s picturesque streets and its quilt museum draw tourists from the around the world. commonwealthfund.org Case Study, July 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 5 INDIANA Within Paducah’s hospital referral region, nine health clinics have opened ILLINOIS or expanded in the past five years. Paducah MISSOURI TENNESSEE to have gotten it,” says Heather Glisson, office manager of Purchase District Health Department, which serves five the clinic, which still provides basic medical services— counties including some of the region’s poorest, also including exams, diagnostic tests, and prescription employed navigators to help uninsured patients obtain medicine—to the working poor with help from volunteer Medicaid coverage if eligible. Together, these efforts may clinicians and support from nearby Murray-Calloway be part of the reason that the region outpaced the state in County Hospital. Since the expansion, its focus has been decreasing the number of at-risk adults who went without on providing short-term assistance—filling a prescription a routine doctor visit in the past two years. or arranging for a test at the hospital. Baptist Health, Lourdes’ competitor, which operates two The organization that ran the St. Nicholas Family Clinic, tertiary care hospitals in the region, extended its primary meanwhile, has shifted its focus to helping working adults care reach by opening a family medicine practice with who earn too much to qualify for Medicaid but can’t afford two physicians and by committing six nurse practitioners to purchase insurance on their own. “Our clients want to to nine school-based clinics. The clinics provide urgent- have insurance but have been priced out of the market,” care services to students and their siblings, parents, says Rayla Bridges, executive director of the St. Nicholas and faculty—billing for services when possible. The Healthcare Payment Assistance Program. The nonprofit’s local behavioral health agency—Four Rivers Behavioral clients receive care from a handful of area providers Health—has deployed staff to the school clinics as well to who offer services at reduced charges and pay between provide behavioral health services, including substance 25 percent and 75 percent of the total bill, depending on abuse counseling. household size and income. St. Nicholas makes up the The community also has rallied to improve vaccination difference. “Our goal is to help clients improve their overall rates for the flu, says Michael Muscarella, executive health so they can keep working and ultimately earn their director of ambulatory services for Baptist Health. “We way out of needing us,” Bridges says. had free flu shot events for the longest time—anyone could come in and get one. Then other providers and pharmacies OTHER EFFORTS TO INCREASE AND began similar flu shot programs and, as a result, during DIRECT ACCESS the cold and flu season we had very few people in our During the period the Scorecard tracked—roughly 2011 hospital who were admitted with the flu,” he says. The to 2014—Lourdes Hospital in Paducah, a 281-bed hospital vaccination push may explain some of the improvement affiliated with the Mercy Health system, partnered with in the percentage of adults with age-appropriate vaccines, KentuckyCare in an effort to direct certain patients to the which increased from 33 percent in 2011–12 to 38 percent health center. These included uninsured patients, those on in 2013–14, placing it in the second quintile of hospital Medicaid, and the working poor who used the hospital’s referral regions nationwide. emergency department as a source of primary care. The commonwealthfund.org Case Study, July 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 6 QUALITY GAINS IN HOSPITAL SECTOR MEDICAID WAIVER During the Scorecard period, Gov. Matt Bevin’s application for a Medicaid waiver—submitted to the the Paducah region also saw U.S. Department of Health and Human Services in late August 2016— improvements on measures of offers a preview of what a redesigned Medicaid program might look like hospital quality, including risk- in Kentucky. The plan is modeled on Indiana’s waiver demonstration; both adjusted 30-day mortality rates were conceived by Seema Verma, M.D., the new head of the Centers for among Medicare beneficiaries Medicare and Medicaid Services, which has authority to approve some hospitalized for heart attack, heart of the plan’s more controversial components, including the requirement failure, pneumonia, or stroke; a that able-bodied adults either work part time, attend school, or engage in hospital safety composite score; the community service to qualify for benefits. percentage of patients who were The proposal, dubbed Kentucky given information about what to do HEALTH, aims to transition Examples of how Medicaid during their recovery at home; and Medicaid beneficiaries to recipients could earn vision hospitalized patients who reported employer-sponsored insurance, if and dental benefits: their pain was managed well. possible, by reimbursing a portion • $150 for registering at a career of their employee contributions. Being part of a larger hospital center and completing a job The alternative for those who are needs assessment system that provides resources for not eligible for employer-based quality improvement initiatives and coverage is a high-deductible • $50 for completing diabetes, benchmarking tools has helped, says health plan, with premiums that cardiovascular disease, Catherine Sivills, Baptist Health’s range from $1 to $15 a month and or other chronic disease marketing director. “That pushes us increase over time. To be eligible management or weight for coverage, adults who are not management course all forward,” she says. exempt would be required to work, • $50 for participating in a attend school, and/or perform smoking cessation course AN UNCERTAIN FUTURE community service for five hours While Kentucky’s Medicaid per week in the first three months, • $50 for passing the GED exam program now covers nearly one increasing to 20 hours per week • Beneficiaries must first of four adults between the ages at the end of the first year.3 To complete work and/or of 19 and 64, its future is unclear. gain vision and dental benefits, community service Beshear’s successor, Republican some beneficiaries would have to requirement to earn Gov. Matt Bevin, views the program complete assignments beyond these rewards these requirements (see box). as financially unsustainable given the state’s pension crisis, its high The waiver imposes penalties for failing to pay premiums within poverty rates, and low rate of labor a designated time frame, including a six-month lockout for some force participation. He’s submitted beneficiaries, and financial penalties for inappropriate use of emergency a proposal to restructure it, which departments; it also eliminates automatic renewals.4 “There are a would preserve the expansion but lot of traps and doors to fall out,” says Gabriela Alcalde, Ph.D., M.P.H., require many who are newly covered vice president of policy and program at the Foundation for a Healthy to contribute to premiums and to Kentucky. Alcalde and others are concerned beneficiaries will not be able work, pursue education, or perform to find work or volunteer opportunities, particularly in rural communities.5 community service to qualify for Continued on next page. benefits, a move that could shrink enrollment (see sidebar). commonwealthfund.org Case Study, July 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 7 How health care providers and the region as a whole will respond to a possible Medicaid reconfiguration or MEDICAID WAIVER (cont’d) repeal of other parts of the Affordable Care Act remains to be seen. The pace at which KentuckyCare has opened David Bolt, the Kentucky Primary Care Association’s clinics—one per year since 2012—may slow to one every deputy director, is hoping that changes to the two or three years if there is a repeal or restructuring state’s Medicaid program won’t derail efforts to of the program, Goodwin says, but KentuckyCare is invest in primary care and will instead spur models committed to the region. “We existed before there was an that integrate medical, dental, and behavioral health Affordable Care Act and we’ll exist after the Affordable services. Like many others in the state, he’d like to Care Act or other permutation.…We just won’t get to move see reform and likes features in the waiver proposal as fast as we’d like to serve the residents of Kentucky.” that encourage personal responsibility and incent healthy behavior. His concern is the execution. The A HISTORY OF COLLABORATION state’s abrupt transition to Medicaid managed care While the Paducah region’s improvement on the Scorecard in 2011 was and continues to be a bumpy one for reflects its nimble response to the Affordable Care Act, hospitals and provider groups, he says—in part its efforts to invest in the community have been under because of inadequate planning, investment, and way for some time and are indicative of strong social ties communication among the state, the managed that can be leveraged to solve problems. These ties may care companies, and providers. be most apparent in the way local businesses, city and county government, and the philanthropic community Without investment and careful planning, the finer in Paducah came together in 2010 to create a scholarship points of the waiver may get lost in translation— program that provides five semesters of free tuition at leading to an approach where spending cuts West Kentucky Community and Technical College to high become the priority, he says. “Just at the point school graduates who have at least a 2.5 GPA, a record we are learning that you really have to treat the of good attendance, and no major disciplinary actions. whole person and the whole community, we are “When a community the size of Paducah can do that, potentially looking at going back to a ‘treat-em-and- anyone can,” Muscarella says. street-em’ modality, which is what got us into the mess in the first place,” Bolt says. The Impact Poverty Task Force also has focused on education, helping to promote literacy in children, as well as building bridges between those in poverty and those who are not so they can better understand one another. Similarly, the community has forged alliances among nonprofits in an effort to reduce duplication of services. Since 2012, charities have been meeting quarterly at a local bank to find opportunities to collaborate, says Monique Sources: Zuber, executive director of the local United Way. “People are very giving and they want to see people succeed,” https://www.healthy-ky.org/res/images/ resources/1115-BRIEF-FINAL-5-9-16.pdf Zuber says. http://kypolicy.org/new-medicaid-waiver-plan-keeps- Community coalitions focused on improving health approach-problematic-original-proposal/ outcomes—by promoting physical activity, reducing http://chfs.ky.gov/NR/rdonlyres/69D38EB6-602F-4707- obesity, and addressing social determinants of health—are 933C-80D5AAE907F7/0/KYHEALTHWaiverFINAL.pdf commonwealthfund.org Case Study, July 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 8 just getting started. The Rotary Club and the Foundation LESSONS for a Healthy Kentucky have contributed to building a new Federal and state policy enabled local action to health park in a low-income neighborhood, including a improve access to care. The Paducah region was able playground, outdoor gym, walking trail, and community to respond quickly to the state’s Medicaid expansion garden. And the Purchase Area Connections for Health—a and take advantage of the infusion of federal funding coalition of local hospitals, health departments, that accompanied it because local leaders had already representatives of city government, the schools, and identified access as a problem they were committed to the United Way—is considering programs to promote addressing. Progress in this area may be compromised by community health improvement, including the possibility proposed changes to the state’s Medicaid program. of pursuing Blue Zones certification for Paducah. (The Blue Zones Project encourages city planners to work with Strong social ties and a record of success in schools and worksites to promote healthy choices in achieving ambitious goals provided a foundation eating and exercise.) for collective action. Paducah has a history of setting and achieving goals for civic improvement—from Changing health outcomes in Paducah will be a long-term attracting world-class artists to building a performing effort, says Goodwin, and it will require more residents to arts center and funding a college scholarship program. change longstanding behaviors. “You can’t change where Burgeoning efforts to collectively address local health you’re ranked nationally if a handful of people change challenges, together with local investments in education their behavior. You need a bunch of folks to say, ‘Let’s start and the economy, may pay dividends in improving health walking. Let’s start riding. Let’s start running. Let’s put outcomes down the line. down the cigarette and pull away from the table. All those things that Grandma said—we need to do those things.’” With barge traffic, the waterways that surround Western Kentucky have served as an economic engine. commonwealthfund.org Case Study, July 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 9 NOTES ABOUT THE AUTHORS 1 The hospital referral region predominately comprises Sarah Klein is editor of Transforming Care, a quarterly counties in Kentucky: Ballard, Caldwell, Calloway, publication of the Commonwealth Fund that focuses Carlisle, Christian, Crittenden, Fulton, Graves, Hickman, on innovative efforts to transform health care delivery. Hopkins, Livingston, Lyon, McCracken, McLean, She has written about health care for more than 15 years Marshall, Muhlenberg, Trigg, Union, and Webster. Parts as a reporter for publications including Crain’s Chicago of the referral region extend into Illinois (Johnson, Business and American Medical News. Ms. Klein received a Massac, Pope, Pulaski, and Williamson counties) and B.A. from Washington University in St. Louis and attended Tennessee (Henry, Obion, and Weakley counties). the Graduate School of Journalism at the University of California at Berkeley. 2 Foundation for a Healthy Kentucky, “Medicaid Enrollment Nears 636,000 in the 2nd Quarter of 2016,” Martha Hostetter, M.F.A., is a writer, editor, and partner news release, Nov. 21, 2016. See: https://www.healthy- in Pear Tree Communications. She was a member of the ky.org/newsroom/news-releases/article/56/medicaid- Commonwealth Fund’s communications department enrollment-nears-636-000-in-2nd-quarter-of-2016. from June 2002 to April 2005, serving as the associate editor and then creating the position of Web editor. She is 3 Children, pregnant women, the medically frail, and currently a consulting writer and editor for the Fund. Ms. those who are caretakers for others are exempt from Hostetter has an M.F.A. from Yale University and a B.A. these requirements as well as some other features from the University of Pennsylvania. of the plan. The Kentucky Center for Economic Douglas McCarthy, M.B.A., is senior research Policy estimates one-half of those who recently director for the Commonwealth Fund. He oversees the gained coverage have jobs—many in the restaurant, Commonwealth Fund’s scorecard project, conducts construction, and retail sectors. case-study research on delivery system reforms and 4 The lockout period may be shortened by attending a innovations, and serves as a contributing editor to the health or financial literacy course. Fund’s quarterly newsletter Transforming Care. His 30-year career has spanned research, policy, operations, 5 The proposal does not mention how the state would and consulting roles for government, corporate, fund the infrastructure necessary to track community academic, nonprofit, and philanthropic organizations. engagement and work activities, arrange for financial He has authored and coauthored reports and peer- and health literacy courses, collect premiums, and reviewed articles on a range of health care–related topics, determine whether those who opt for employer- including more than 50 case studies of high-performing sponsored health insurance have benefits that are organizations and initiatives. Mr. McCarthy received his equivalent to the state’s plan. bachelor’s degree with honors from Yale College and a master’s degree in health care management from the University of Connecticut. He was a public policy fellow at the Hubert H. Humphrey School of Public Affairs at the University of Minnesota during 1996–1997, and a leadership fellow of the Denver-based Regional Institute for Health and Environmental Leadership during 2013– 2014. He serves on the board of Colorado’s Center for Improving Value in Health Care. commonwealthfund.org Case Study, July 2017 How Western Kentucky Leveraged Medicaid Expansion to Increase Access to Health Care 10 ACKNOWLEDGMENTS For more information about this brief, please contact: The authors thank the following individuals who Douglas McCarthy generously shared information and insights for the case Senior Research Director study: Gabriela Alcalde, vice president of policy and The Commonwealth Fund program, Foundation for a Healthy Kentucky; David Bolt, dmcmwf.org deputy director, Kentucky Primary Care Association; Rayla Bridges, executive director, St. Nicholas Healthcare About the Commonwealth Fund Payment Assistance Program; Brad Davis, associate The mission of the Commonwealth Fund is to promote a director, Purchase Area Development District; Amy high performance health care system. The Fund carries Ferguson, public health director, Calloway County out this mandate by supporting independent research on health care issues and making grants to improve health care Health Department; Heather Glisson, office manager, practice and policy. Support for this research was provided Angels Community Clinic; Emerson Goodwin, corporate by the Commonwealth Fund. The views presented here regional director, KentuckyCare; Brandi Harless, mayor, are those of the authors and not necessarily those of the city of Paducah; Laura C. Hawes-Hammons, public Commonwealth Fund or its directors, officers, or staff. health director, Marshall County Health Department; Ian McFadden, executive director, Pennyroyal Mental Health Vol. 21. Center; Keena Miller, director of health and wellness, rehabilitation, and occupational medicine, Murray- Calloway County Hospital; Jesse Morrison, manager of market planning and analytics, Lourdes Hospital; Michael Muscarella, executive director of ambulatory services, Baptist Health; Dustin Pugel, research and Commonwealth Fund case studies examine health policy associate, Kentucky Center for Economic Policy; care organizations that have achieved high per- F. Douglas Scutchfield, M.D., professor of health services formance in a particular area, have undertaken research and policy, University of Kentucky; Catherine promising innovations, or exemplify attributes that Sivills, marketing director, Baptist Health; Jennifer Beck can foster high performance. It is hoped that other Walker, executive director, Purchase Area Development institutions will be able to draw lessons from these District; John Williams, Sr., founder, Computer Services; cases to inform their own efforts to become high and Monique Zuber, executive director, United Way of performers. Please note that descriptions of prod- Paducah-McCracken County. ucts and services are based on publicly available information or data provided by the featured case study institution(s) and should not be construed as Editorial support was provided by Ann B. Gordon. endorsement by the Commonwealth Fund. Photos by Glenn Hall. commonwealthfund.org Case Study, July 2017