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The Commonwealth Fund's State Scorecard--How Will States Translate the Findings into Action?

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Feature: The Commonwealth Fund's State Scorecard—How Will States Translate the Findings into Action?

The Commonwealth Fund's Commission on a High Performance Health System recently published Aiming Higher: Results from a State Scorecard on Health System Performance. The State Scorecard is designed to examine variation across the states on 32 indicators of health system performance related to access, quality, avoidable hospital use and costs, equity, and healthy lives. It reveals an unfortunate truth: where you live has a direct impact on your access to, and quality of, health care. By identifying the correlations between health care access and quality, and by illustrating areas in which states have room to improve, the Fund hopes to catalyze discussions at the state and federal levels on what steps are needed to improve health system performance and contain costs across the nation.

The State Scorecard estimates the cost savings and improved health outcomes that could be achieved if middle- and low-performing states implemented policies and strategies similar to those executed by the highest performers. For example, if all states:
  • had low mortality rates similar to those of high performers, there would be 90,000 fewer deaths annually among the under 75 population;
  • achieved insurance coverage rates similar to those of the top states, the number of uninsured across the nation could be cut in half;
  • improved their chronic care systems to match those developed by the top states, nearly 4 million diabetics could avoid preventable and expensive complications.
The State Scorecard was developed, in part, to uncover strategies leading to high performance, and to identify states that have undertaken these strategies.

Across the board, higher performance is associated with state policies that improve access and quality. For example, Hawaii—the first state to require employers to provide health insurance to full-time employees—ranks first in terms of providing access to care. Ten years ago, Rhode Island implemented pay-for-performance incentives for Medicaid managed care plans, and the state now ranks first on several measures of health care quality.

The State Scorecard results can motivate and focus states as they work to improve their health systems. Toward that end, the Fund is facilitating a series of forums through which states can disseminate the information provided through the Scorecard and begin a dialogue on opportunities for creating systems and models that meet their residents' needs.

The State Scorecard identified 13 states—Hawaii, Iowa, New Hampshire, Vermont, Maine, Rhode Island, Connecticut, Massachusetts, Wisconsin, South Dakota, Minnesota, Nebraska, and North Dakota—as "top performers," with high rankings across multiple indicators in the five areas of health system performance noted above. Across all indicators, the following trends emerged:
  • top-performing states had very low rates of uninsured;
  • there was a strong connection between access to care and quality, with states that achieved high marks for access also receiving high marks on quality measures;
  • even high-performing states have room to improve.
Other findings include:
  • Access: In general, insurance rates among adults are dropping. The number of states with 23 percent or more uninsured adult residents has tripled over the last five years as coverage has become less affordable or accessible. By contrast, rates of insurance among children have increased as public programs such as the State Children's Health Insurance Program (SCHIP) have expanded. Twelve states report a rate of uninsured children below 7 percent.
  • Quality: Across states, there is wide variation in health care quality. The Scorecard found variation within, as well as across, three broad indicators of health care quality: coordination of care; patient-centered care; and receipt of evidence-based or effective care. Even in Hawaii, which ranked among the top performers overall and highest in terms of receipt of effective care, only 65 percent of diabetics receive the care they need. There is also wide variation in hospital quality, with states falling short on a number of indicators, such as providing antibiotics before and after surgery and providing written instructions upon discharge for patients with congestive heart failure. One positive finding: nearly all states do well in delivering children's immunizations.
  • Potentially Avoidable Use of Hospitals and Costs of Care: There is extraordinary variation across the states in rates of potentially preventable hospital admissions, with two- to threefold differences in rates of readmissions within 30 days of hospital discharge and similar variation in rates of nursing home readmissions. States with high 30-day hospital readmission rates had 38 percent higher Medicare costs than those with the lowest readmission rates.
  • Equity: Not surprisingly, across the nation, patients with high incomes and/or health insurance had better health outcomes than those with lower incomes or no health insurance. Even in states where low-income and uninsured residents have access to care, high-income, insured residents are healthier. The State Scorecard profiles state-level health care disparities by race. For example, it finds that the mortality rate among African Americans under age 75 is more than twice that of whites nationwide.
State Forums
The Fund partnered with the State Health Policy Centers Collaborative (SHPCC) and individual states to develop forums to provide opportunities for stakeholders to discuss the State Scorecard results, identify opportunities for improvement, and explore policy options. SHPCC is a participant-driven group committed to improving people's health, health care, and well-being by advancing non-partisan and evidence-based research, policy analysis, and information-sharing on state and federal policies and programs. [1]

The Commission on a High Performance Health System has identified strategies and policies that have led to improvements in some states. These include:
  • Expanding health coverage by: developing coverage options that spread responsibility between the state, employers, and individuals; pooling purchasing power; and promoting new benefit designs to increase affordability.
  • Improving health care quality and efficiency by: promoting value-based benefit designs, pay-for-performance, and use of tiered provider networks; promoting better use of hospital information technology, transitional care at hospital discharge, and development of medical homes; and promoting wellness and healthy living initiatives, improving chronic care management, and developing collaborative processes for sharing data, information, and process improvement practices.
Thus far, forums have been held in Arkansas, California, Kansas, Ohio, and Wisconsin while Louisiana, Rhode Island, and other states are planning forums for the fall. Participant groups have included providers, hospitals, public health agency staff, legislative staff and members, consumer advocates, payers, and employers. As first steps in a longer-term process, the forums will help states determine the opportunities and challenges for improving their systems to reach—and potentially surpass—the current top performers. Below we discuss efforts to improve health system performance in California and Louisiana.

The Center for Health Improvement (CHI) in California convened a forum in June for state legislative and agency staff as well as consumer advocates, researchers, and providers. In response to the state's low ranking on health care quality on the State Scorecard, the forum focused on ways to improve quality and examined the relationship between quality and access to care. The panel discussed current health care reform proposals, including Governor Schwarzenegger's proposals and two legislative bills, given the fact these proposals prioritize access to care, prevention, and chronic care management.

While many challenges remain, there appears to be much interest by the Republican governor and the two Democrat legislative leaders in reaching consensus on health reform after the legislature reconvenes on August 20. Regardless of the outcome, the CHI is planning another forum in the fall, which will again focus on health care quality and health system improvement. They are also working with targeted stakeholder groups to develop strategies to put health care quality on the reform agenda.

According to Karen Shore of the CHI, members of the State Health Policy Collaborative want to leverage the wealth of information offered by the State Scorecard to make an impact on health care system reform—not just in their own states, but across the country. She notes that "there is power in numbers": the more states take advantage of the Scorecard, the more powerful a tool it will become.

The Louisiana Public Health Institute (LPHI), a member of the SHPCC, and the recently established Health Care Quality Forum (see Profile on Louisiana), are leading an effort to develop an agenda for a State Scorecard forum, set for the end of September. The audience will include providers, state agency staff, employers and other payers, consumers, and insurers as well as representatives from the state's legislative and executive branches.

According to Eric Baumgartner, director of Policy and Program Planning for LPHI, the agenda will focus on health care quality and what can be done to improve the state's performance. Participants will discuss examples from high-performing states and consider policies these states implemented to create systems of care that consistently deliver high-quality, low-cost services, including efforts to expand coverage through benefit design and use of information-sharing technologies to improve quality.

To promote action, the forum will facilitate dialogue on quality improvement, filling gaps in the data, state health care funding, and incentives in place to promote high performance. "The forum will give all stakeholders a better sense of how the state is doing, and how to move on from here," says Baumgartner. "We want the audience to come away with an understanding of the inextricable interdependence between all levels of the system—government, patients, providers, etc.—and that there are strategies that can be employed to achieve better value for private and/or public dollars."

The State Scorecard demonstrates what is achievable and provides indicators to compare state performance over time. It enables states to compare themselves to others in their region, as well as to the top performers. Even the top-performing states have room to improve, and many lower-performing states have already made significant strides in various aspects of their health care systems. Moving forward, the Fund hopes that the State Scorecard will help state and federal policymakers address the gaps in our health system—both within and across states—ensuring that everyone has access to high quality, equitable health care, regardless of where they live.

[1] Based at the National Academy for State Health Policy (NASHP), SHPCC's current members include state health policy centers, institutes, and university-based research organizations located in Arkansas, California, Colorado, Florida, Georgia, Kansas, Louisiana, Maine, Massachusetts, Mississippi, New Jersey, North Dakota, Ohio, Texas, Washington, West Virginia, and Wisconsin.

For More Information
Contact: Cathy Schoen, Senior Vice President for Research and Evaluation, The Commonwealth Fund, [email protected]
See: Aiming Higher: Results from a State Scorecard on Health System Performance

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