The Commonwealth Fund's 2009 State Scorecard on Health System Performance—much like its inaugural version in 2007—finds a mixed bag in terms of quality healthcare. On one hand are deteriorating health insurance coverage for many adults and rising healthcare costs, but on the other hand there are signs of improved quality of care processes and better coverage of children. However, each state has its own story to tell.
"Where you live really does matter in terms of your ability to access the healthcare system and the quality that you receive," said Rachel Nuzum, senior policy director with the Commonwealth Fund's Washington office. "We've seen that wide variation continues to exist between the states in terms of the top performers and the lower performers. And, the gap is growing."
The scorecard looked at all states using four major categories:
- Access to care (by both children and adults)
- Prevention and treatment (including screening and preventive care, surgical infections, and provider interactions)
- Avoidable hospital use and costs (including pediatric admissions and short-stay nursing home residents with hospital readmissions within 30 days)
- Healthy lives (including mortality rates, adults who smoke, and children who are obese)
"Sometimes there is much as a two- to three-fold spread between the top and bottom states," Nuzum said. "That's a huge difference." Most of these difference occurred in the areas of access and quality.
Similar to two years ago, nearly the same 13 states rose to the top quartile and outperformed their peers on multiple indicators: Vermont, Hawaii, Iowa, Minnesota, Maine, New Hampshire, Massachusetts, Connecticut, North Dakota, Wisconsin, Rhode Island, South Dakota, and Nebraska. Many of these states have been leaders in reforming and improving their health systems—for example, by targeting efforts to reduce rates of uninsured adults and children, the report noted.
Ten of the 13 states in the lowest quartile of performance—Tennessee, Alabama, Florida, Kentucky, Texas, Nevada, Arkansas, Louisiana, Oklahoma, and Mississippi—also ranked in the bottom quartile in the 2007 State Scorecard. Three other states—North Carolina, Illinois, and New Mexico—descended from the third quartile, while California, West Virginia,and Georgia moved up out of the last quartile. Rates of uninsured adults and children were on average double those in the top quartile of states.
Among the states that moved up the most in the overall performance rankings, Minnesota rose within the top quartile to become the fourth ranked state, showing significant improvement on multiple indicators. Three states: Arkansas, Delaware, and West Virginia, plus the District of Columbia—had at least half of their performance indicators improve by 5%.
Some of the leading states set new benchmarks for 20 of the 35 indicators with trends. These patterns indicated that public policies at the state and local levels could make a difference, according to the report. Vermont, Maine, and Massachusetts, for example, have enacted comprehensive reforms to expand coverage.
And Minnesota proved to be a leader in bringing together public- and private sector stakeholders in collaborative initiatives to improve the overall value of healthcare, Nuzum said. This is an approach that appears to be gaining ground in other states.
Other highlights of the report:
- The quality of hospital care for heart attack, heart failure, pneumonia, and the prevention of surgical complications improved sharply, as all states gained ground and the variation across states narrowed. The improvement takes into account the impact of national efforts by Medicare to measure and benchmark performance.
- Key indicators of nursing home and home healthcare quality improved 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.
- Ambulatory care quality indicators, including preventive care, changed little or declined in half the states, with wide gaps persisting across states.
- In many 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, increases in hospital admissions have occurred and readmissions from nursing homes, as well as hospital admissions for home healthcare patients. These indicators point to a lack of incentives for effective transitional care and care management, the report noted.
"There's been a lot of talk of international models. We think there is a lot of value to that. But at the same time, we know we're in a kind of uniquely American situation here with the way that our system is constructed," Nuzum said. "And some really innovative creative things are happening at the state level."
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