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Spreading State Success

The recently released State Scorecard on Health System Performance, the latest report from the Fund's Commission on a High Performance Health System, reveals that, to a great extent, the state you live in affects your health care. Given that every American should have access to high-quality, equitable, and cost-effective health care, the State Scorecard was developed to help states identify ways they can improve care for their residents.

The State Scorecard rates states on 32 performance indicators of access, quality, avoidable hospital use and costs, equity, and "healthy lives." The rankings for indicators within these dimensions demonstrate sharp differences between the top and bottom states, suggesting that federal and state policies, as well as regional health systems, play an important role in health care.

For example, the 14 leading states have the most extensive publicly sponsored insurance programs, with income thresholds that support low- and modest-wage workers and their families. Additionally, 12 of the 14 leading states have maintained all-payer hospital databases; in the New England states, these information systems have enabled benchmarking across payers and assisted collaborative quality improvement efforts. Indeed, public-private collaborations that focus on the entire community are occurring in many of the high-performing states.

Rather than create new policies from scratch, states can learn from other states' policies and programs–many of which improve access and quality without raising health system costs. So let's take a look at some of the innovative state programs already in place, and how they help achieve a high-performing health system. The key strategies are:

  • extend health insurance to all;
  • promote effective cost-control strategies;
  • organize the health care system;
  • pursue and raise benchmark levels of high-quality, safe, effective, and efficient care and enhance the system's capacity to innovate and improve; and
  • shape a coherent set of health care policies through national leadership and public-private collaboration.

Case in Point
Extend Health Insurance to All: Hawaii, Maine

Hawaii ranks first in the State Scorecard–an achievement that may be due in part to its early efforts to cover its residents. The state's 1974 Prepaid Health Care Act mandated that employers–with a few exceptions such as seasonal employers and government services–provide insurance to all employees working more than 20 hours a week. Employers must pay 50 percent of premiums, but can require employees to contribute up to 1.5 percent of their wages. Other residents, including employees working less than 20 hours a week, the self-employed, and Medicaid beneficiaries, receive coverage under a public program called the State Health Insurance Plan. The legislation also mandates that insurance plans offer certain benefits, including hospital and surgical benefits, maternity benefits, and laboratory services.

State reforms in the 1990s were eclipsed by the failed attempt at national reform. It was not until the following decade that the next comprehensive state coverage initiative was enacted and implemented: Maine's Governor John Baldacci signed the Dirigo Health Reform Act (PL 469) into law in June 2003. Dirigo aims to make quality, affordable health care available to every Maine citizen within five years and to initiate new processes for containing costs and improving health care quality.

Maine's Medicaid program has been expanded to cover all adults below 100 percent of the federal poverty level, and parents below 200 percent of the federal poverty level. In addition, the Reform Act created a new insurance product, DirigoChoice, with a maximum deductible of $1,250 and lower sliding-scale deductibles and premiums available to residents with incomes below 300 percent of the federal poverty level. Employers that don't cover workers may voluntarily pay a fee covering 60 percent of the worker's premium for DirigoChoice. As of December 2, 2006, enrollment in DirigoChoice was up to 13,290, short of the 41,000 anticipated. In April, Gov. Baldacci proposed a series of reforms to improve the program, including requiring people to have insurance, collecting mandatory fees from employers who do not provide coverage, and making the subsidized insurance plan more affordable.

Case in Point
Promote Effective Cost-Control Strategies: New York, Rhode Island

In both the private and public sectors, purchasers are working to lower spending and improve health care quality through pay-for-performance activities. Developed in 2001, the New York Medicaid managed care program provides incentives for plans with high quality ratings. The program evaluates plans using measures of adult and children's health care from New York State's Quality Assurance Reporting Requirements, a set of performance measures mostly derived from Health Plan Employer Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data. Plans that perform well are rewarded with new members, as well as bonuses paid monthly as part of the per-member premiums.
In addition to this program, New York, ranked 22nd, has offered five grants for regional demonstration projects involving collaborations between multiple insurers and providers to test innovative approaches to pay-for-performance.

Rhode Island, ranked sixth in the Scorecard and first on quality, has been a leader in incorporating quality improvement in its public insurance programs. Rhode Island's Medicaid managed care program, RIte Care, has had a pay-for-performance program for almost 10 years. As in New York, RIte Care rewards health plans using performance measures based on HEDIS and CAHPS measures for administrative service, access, and clinical quality. Developing medical homes for plan members has been a particular program focus. Since 2005, RIte Care has also had an incentive program for physicians, designed to expand access to primary care—by strengthening preventive and off-hours care—and reduce the number of emergency room visits.

Case in Point
Organize the Health Care System: Iowa, Connecticut

Many states control costs though primary care case management, which is designed to improve the coordination of care and eliminate use of unnecessary services, particularly specialty and emergency room care. In Iowa, ranked number two in the State Scorecard, the primary care case management program known as the Medicaid Patient Access Service System (MediPASS) was established in 1990.

Under MediPASS, general practitioners, family practitioners, general internists, obstetrician-gynecologists, and pediatricians act as primary care case managers. A cost analysis of Iowa's program published in the August 2006 issue of the journal Health Research and Educational Trust found that, over an eight-year period, the program was associated with substantial cost savings of $66 million. Notably, the program changed where and how care was delivered, with an increase in outpatient care and a decrease in hospital and physician expenses—resulting in reduced total costs.

In Connecticut, ranked seventh, the Connecticut Children's Trust Fund started the Help Me Grow program—in collaboration with The Commonwealth Fund, The United Way of Connecticut/ Infoline, the Connecticut Birth to Three System, and the state's Department of Education Preschool Special Education Program—to streamline the identification and treatment of developmental problems in young children. Help Me Grow trains and supports pediatric practitioners in screening and assessing children (birth to age 5) who are at risk of developmental, health, or behavioral problems, and in eliciting parents' opinions and concerns. The program then matches children and their parents with needed services through a centralized referral and case management system. To make connections between families and resources, the program offers a toll-free phone line and partnerships with community-based agencies.

Case in Point
Pursue and Raise Benchmark Levels of High-Quality, Safe, Effective, and Efficient Care and Enhance System Capacity to Innovate and Improve: North Carolina, South Dakota

The nonprofit Community Care of North Carolina (CCNC) was established in 1998 to develop badly needed coordination at the local level, thereby controlling costs and improving care. CCNC worked to build cost-saving networks that joined physicians with other community providers, including hospitals, health departments, and departments of social services. Today, there are 15 networks with more than 3,500 doctors who provide medical homes to more than 715,000 enrolled patients, according to L. Allen Dobson, Jr., M.D., FAAFP, assistant secretary in the North Carolina Department of Health and Human Services.

North Carolina, ranked 30th, supports the program by providing $2.50 per Medicaid enrollee to the network, and an additional $2.50 to primary care providers for serving as a medical home and participating in disease case management. As part of the program, statewide quality improvement initiatives have been launched, including standardized developmental screening in well-child care, asthma management and diabetes management—all of which have led to improved care. Two new quality improvement initiatives will address mental health and chronic obstructive pulmonary disease. CCNC also provides physicians with quarterly feedback on their performance.
South Dakota, ranked 10th, has a number of innovative, collaborative programs at work that are leading to better care. South Dakota's Partners for Prevention Project, administered by the South Dakota Dental Association (SDDA), is seeking to enhance dental care for low-income Medicaid-enrolled children by training medical primary care providers to detect dental disease, training general dentists in pediatric dental techniques, and providing parents with prevention information about oral health. The state's goal is to increase the number of Medicaid-enrolled children ages 1 to 5 that have access to dental services by 25 percent over five years. The SDDA has begun to evaluate the training sessions and is developing ways to assess outcomes of the program.

Case in Point
Shape a Coherent Set of Health Care Policies Through National Leadership and Public-Private Collaboration: Wisconsin, Kansas

In Wisconsin—ranked number nine in the State Scorecard—a voluntary public-private consortium was formed in 2003 to enhance transparency and promote quality in the health care system. The Wisconsin Collaborative for Healthcare Quality (WCHQ) includes physician groups, hospitals, health plans, employers, and labor organizations. WCHQ publicly reports comparative information on its members through an interactive Web-based tool. The reports are organized into measures drawn from the Institute of Medicine's dimensions of health care quality, as well as topics such as access, use of information technology, heart care, pneumonia, and patient satisfaction.
In Kansas, ranked 20th, the Health Information Exchange Commission, announced in February 2007, is working to coordinate and focus the state's efforts to improve health care quality and promote cost-effective care delivery through the use of information technology (IT). This public-private effort involves health care sector representatives, government, IT and health policy experts, and consumers.

Aiming Higher
The State Scorecard demonstrates that there are wide gaps in health system performance among states. States that set benchmarks in certain dimensions of care—as well as states with innovative policies and programs—offer models of care that poorer-performing states can tailor to the needs of their residents. As the authors of the State Scorecard emphasize, every state, and the nation as a whole, should aim higher when it comes to providing affordable health care.

You can review your own state's performance, as well as an analysis of the impact on health care access, cost, and lives if your state were to achieve top levels of performance, on the State Scorecard interactive U.S. map at


As always, I'm interested in your feedback. Please e-mail me at [email protected].



IMPORTED: www_commonwealthfund_org__usr_img_davis_sig.gif
June 2007


Written with the assistance of Christine Haran, web editor.