The report, Aiming Higher: Results From a State Scorecard on Health System Performance, was released two days after the Agency for Healthcare Research and Quality released its State Snapshots, which evaluated each state and the District of Columbia based on 129 quality measures. In it, AHRQ found that on average, about 59% of Medicare-insured adult surgery patients received appropriate timing of antibiotics, and that only about 54% of Medicare managed-care patients said their health providers always listened carefully, explained things clearly and showed respect for what they had to say.
But while the AHRQ study found gains and shortcomings specific to the sole performance area of quality, the Commonwealth Fund report is unique because it examined five areas of health system performanceaccess, quality, potentially avoidable use of hospitals and costs of care, equity and healthy livesto show states and the District of Columbia how they fared and how they could improve.
Some of the more notable findings include the wide variations among states in the five dimensions; the idea that higher quality does not translate into higher costs; and that even in the best states, performance does not meet optimal standards.
And the report contained stark statistics demonstrating the cost of lower performance. If all states could approach the low levels of mortality from conditions amenable to care achieved by the top state, nearly 90,000 fewer deaths before the age of 75 would occur annually, it said.
Similarly, if all states reached the low levels of potentially preventable admissions and readmissions, hospitalizations could be reduced by 30% to 47% and save Medicare $2 billion to $5 billion each year.
To our knowledge, this is the first time anyone has attempted to take a comprehensive view for states to take priorities, said Joel Cantor, lead author of the Commonwealth Fund study and director of the Center for State Health Policy at Rutgers University. Using a common metric to compare states lets them know how they are doing. The utility of the report is its comprehensiveness and then the states can benchmark themselves. Having said that, one of the findings that leapt out is how closely access and quality track with each other.
This is true in Texas, which ranked 51st for access and 46th for quality in the State Scorecard. The state had an overall ranking of 49, just above Mississippi and Oklahoma, which tied for 50th.
I dont see any of this as surprising, said Dan Stultz, president and chief executive officer at the Texas Hospital Association. I think the scorecard matches what we as an association in Texasand what we have nationally thoughtwhich is that people do worse without some network of care.
According to the association, Texas has the nations highest rate of people without health insurance, with an estimated 24.6% of the total population, or about 5.5 million Texans, without coverage in 2005. The state also has a higher share of uninsured children compared with the national average (20.3% in 2005, compared with the national average of 11.6%), as well as higher premiums for employer-sponsored health insurance. In 2006, the average premium for private employer coverage in Texas was $4,530 for an individual and $12,780 for a family, compared with the national average of $4,242 for individuals and $11,480 for family coverage, the association reports.
Stultz also cited Texas diverse demographics, which include a large Hispanic population with higher levels of diabetes and obesity than the general U.S. population. This is a factor that does not have as strong an impact in, say, Vermont or New Hampshire, which both fared well in the rankings. In the State Scorecard, researchers concluded that the nation would insure 22 million more adults and children if all states moved to the level of coverage provided in the top-performing states.
Texas took steps toward that goal just last week. On June 14, HHS Secretary Mike Leavitt joined Texas Gov. Rick Perry, who signed legislation to change the states Medicaid program, which serves more than 2.7 million Texans. The bill also creates a health opportunity pool, which will fund a premium-assistance program to help uninsured working Texans not eligible for Medicaid to buy private insurance.
Access is also a problem in neighboring Oklahoma, said Craig Jones, president of the Oklahoma Hospital Association. Like Stultz, Jones was not surprised by findings in the report, but said it focuses attention on the need for greater dialogue on national health policy. He said its important to look at the individual drivers that lead to variations among the statessuch as a high illegal immigrant population in Texas, or Oklahomas challenge in attracting physicians to rural areas. But like Texas, Oklahoma is working to effect change. Earlier this year, community leaders joined forces to form the Health Alliance for the Uninsured, which seeks to involve hospitals, physicians and community stakeholders to improve a communitys overall health (April 23, p. 6).
This idea of cooperation among many players underscores the message of healthcare leaders in states that ranked very high in the State Scorecard, and could be useful in helping lower- performing states improve.
I know one of the things that has helped Wisconsin is that we have a spirit of collaborationespecially with regard to quality, said Dana Richardson, vice president of quality initiatives at the Wisconsin Hospital Association. We share and work together and leverage each others strengths in order to move our state forward, she said, adding that collaboration among hospitals, the state Department of Health and Family Services, employer coalitions and insurers is unique because these stakeholders often compete with each other.
While Wisconsin ranked ninth overall and eighth for quality, it was 16th in the category of healthy lives, an area that Richardson said needs improvement. For example, she cited the states high rates for smoking and obesity, and said that while hospitals can provide support and education, there needs to be involvement from the entire community to make a difference. This philosophy that high-ranking states should not grow complacent is another notable assessment in the State Scorecard.
Even in the best states, performance falls far short of optimal standards, the report said.
John Brumsted, chief quality officer at Fletcher Allen Health Care in Burlington, Vt., said he was very pleased that Vermont did well (it ranked third overall), but added that: We dont want to get lulled into a false sense of thinking that the work is totally done. Next month, the governing body of the Vermont Medical Society will review the State Scorecard findings to see how Vermont compared with other states and to develop policy recommendations, said Paul Harrington, executive vice president of the society.