Aiming Higher: Results from a State Scorecard on Health System Performance, 2009

October 8, 2009

Authors: Douglas McCarthy, M.B.A., Sabrina K. H. How, M.P.A., and Cathy Schoen, M.S., The Commonwealth Fund

Joel C. Cantor, Sc.D., and Dina Belloff, M.A., Rutgers University Center for State Health Policy

Prepared for the Commonwealth Fund Commission on a High Performance Health System

Feature

State Scorecard Map Use this map to view state-specific rankings and results, and to view the number of lives and dollars each state could save by achieving benchmark levels of performance. Also check out the comparison tool to select years, performance indicators, and states and then generate custom tables and bar charts.

Overview

Focused on identifying opportunities to improve, The Commonwealth Fund's State Scorecard on Health System Performance assesses states’ performance on health care relative to achievable benchmarks for 38 indicators of access, quality, costs, and health outcomes. The 2009 State Scorecard paints a picture of health care systems under stress, with deteriorating health insurance coverage for adults and rising health care costs. On a positive note, there were gains in children's coverage as a result of national reforms, and improvement in some measures of hospital and nursing home care following federal efforts to publicly report quality data. The scorecard highlights persistent wide variation in performance across states and continued evidence of poor care coordination. Increasing cost pressures and deterioration in access across the U.S., together with geographic disparities in performance, underscore the urgent need for comprehensive national reforms to ensure access, change the trajectory of costs, and enhance value.

Executive Summary

The 2009 edition of The Commonwealth Fund's State Scorecard on Health System Performance finds deteriorating health insurance coverage for adults and rising health care costs, but also improved quality of care on dimensions of performance that have been the focus of public reporting and incentive programs. As reported in the inaugural State Scorecard in 2007, where you live within the United States makes a difference in your access to care, quality of care, and experiences with care providers. The findings of this report point to the urgency of comprehensive national health system reforms aimed at improving health system performance across the country, eliminating disparities, and enhancing and assisting states' efforts to address population health needs and ensure affordable access.

With a central focus on identifying opportunities to improve, the State Scorecard provides a framework for state and federal action to address common concerns as well as specific areas of need. It assesses states' performance relative to what is achievable, based on benchmarks for 38 indicators of access, quality, costs, and health outcomes. The findings highlight continued wide variability in performance across states. But they also show that all states face challenges posed by rising costs of care and poor care coordination. Although the scorecard does not yet reflect the impact of the economic downturn—given the two- to three-year time lag in data reporting—the deterioration seen in access to care across the country underscores the need for coherent reforms that would change the trajectory of costs, ensure access, and enhance value.

Overall, the 2009 State Scorecard paints a picture of health care systems under stress. Still, improvements made in certain indicators and in certain areas of the U.S. indicate that individual states have the capacity to do much better, especially when their efforts are supported by strong federal policy and national initiatives. In 2009, Vermont, Hawaii, Iowa, Minnesota, Maine, and New Hampshire lead the nation as the top-ranked states (Hawaii and Iowa tied for second place; Maine and New Hampshire tied for fifth). Their performance ranks in the top quartile of states on a majority of scorecard indicators. In particular, the reforms passed by Vermont in 2006 to cover focused on preventing and controlling chronic disease are providing a new model for other states.

Thirteen states—Vermont, Hawaii, Iowa, Minnesota, Maine, New Hampshire, Massachusetts, Connecticut, North Dakota, Wisconsin, Rhode Island, South Dakota, and Nebraska—again rise to the top quartile of the overall performance rankings, outperforming their peers on multiple indicators (Exhibit 1). Conversely, states in the lowest quartile often lag the leaders in multiple areas. The persistent wide geographic variation points to the need for national reforms to ensure high performance across the country.

Following are some of the cross-cutting state findings and key trends gleaned from analysis of the scorecard results:

Since the beginning of the decade, insurance coverage in most states has been eroding for adults while increasing or holding steady for children. This divergence reflects the impact of federal action to expand coverage for children through the Children's Health Insurance Program (CHIP); rates of uninsured children in 2008 were the lowest since 1987. Nevertheless, high and rising rates of uninsured adults in many states underscore the need for comprehensive national reform to expand coverage in all states, and to further the gains made in Massachusetts, Vermont, and other states that have taken a lead in enacting reforms.

  • The quality of hospital care for heart attack, heart failure, pneumonia, and the prevention of surgical complications improved dramatically, as all states gained ground and the variation across states narrowed. This improvement reflects the impact
    of national efforts by Medicare to measure and benchmark performance.
  • Key indicators of nursing home and home health care quality improved substantially in nearly all states, with declines in rates of pressure ulcers, physical restraints, and pain for nursing home residents and improved mobility for home care patients. Notably, these long-term care quality metrics have also been the focus of public reporting and collaborative improvement initiatives.  Exhibit 1S
  • Ambulatory care quality indicators, including preventive care, changed little or declined in half the states, with wide gaps persisting across states.
  • In a majority of states, symptoms of poor care coordination and continued inefficiency in the use of resources are evident in the increasing rates of hospital readmissions. And in most states, there have also been increases in hospital admissions and readmissions from nursing homes, as well as hospital admissions for home health care patients. These indicators point to a lack of incentives for effective transitional care and care management.
  • States with the highest readmission rates also tended to have the highest costs of care overall—signaling a need for a systematic approach to addressing cost concerns.
  • Rising costs are making care and coverage less affordable for a growing share of families. Across the country, insurance premiums are rising faster than middle-class family incomes.
  • Differences in how well the health care system functions for people based on their income level, health insurance status, and race/ethnicity—what is referred to here as the "equity gap"—were more likely to widen than narrow. Distinct regional patterns and sharp differences in performance across states—with some persistent gaps even in the best-performing states—attest to the reality that our health care system fails to provide reliable access to the affordable, effective, patient-centered, coordinated care that everyone should expect, given the large and growing share of the nation's economic resources that are invested in the health care sector.

Distinct regional patterns and sharp differences in performance across states—with some persistent gaps even in the best-performing states—attest to the reality that our health care system fails to provide reliable access to the affordable, effective, patient-centered, coordinated care that everyone should expect, given the large and growing share of the nation’s economic resources that are invested in the health care sector.