State Health System Performance 

Karen Davis, Ph.D., President
The Commonwealth Fund  

            Our states’ role in public health is evolving.  Historically, states have been responsible for much of our nation’s public health – ensuring safe food and environments, protecting against infectious diseases, investigating disease outbreaks, licensing health care professionals and facilities and providing health care services, such as maternal and infant health clinics, primary care clinics and public hospitals as a “safety net” to ensure the availability of care for uninsured, low-income and disadvantaged populations.  But, in the absence of federal leadership, states are now also tackling many of the problems that give rise to poor health system performance previously thought of as outside of their traditional role.  These include gaps in health insurance coverage, a health care delivery system that has inadequate primary care capacity and an abundance of fragmented, high-cost specialty and institutional care, and slow development of modern systems and tools that would ensure safe, reliable, coordinated care including data on health system performance and application of health information technology and system redesign.  These expanded roles for states provide potential leverage points to promote better access, higher quality and greater efficiency.

Information on State Health System Performance

Given these new and expanding state roles, information on different aspects of health system performance is of great value to state officials and health care leaders. America’s Health Rankings: A Call to Action for People and Their Communities, funded by United Health Foundation in partnership with the American Public Health Association and Partnership for Prevention, is a particularly valuable resource, tracking measures of successes and challenges at the state level since 1990 including key measures of health outcomes, disease incidence, health care services and insurance, and risk factors.[1]

In addition, the Centers for Medicare and Medicaid Services has recently released state data on personal health expenditures, permitting states to assess the value they are obtaining for the health system resources they are devoting to health care.[2]  Recent state-by-state reports on quality by the Agency for Healthcare Research and Quality and the state scorecard on health system performance by the Commonwealth Fund Commission on a High Performance Health System constitute a rich database to inform state and national health policy and stimulate further research and analysis of the determinants of and inter-relationships among dimensions of performance.[3]

Together these statewide data should advance understanding of variations in health system performance, an awareness of the risk factors that pose threats to the health of the public and the actions that states can take to improve the health care delivery system as well as traditional public health measures.  By noting which states do well on which measures, states also have an opportunity to learn from practices of other states and to set realistic targets for health system improvement.[4]

Transforming Health System Performance

The Commonwealth Fund established the “Commission on a High Performance Health System” in 2005 to support research and provide information that will help policymakers and public and private stakeholders address problems arising from our fragmented health care system and move us toward better access, higher quality, and greater equity and efficiency.[5]  In 2006, the Commission published a report, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, that comprehensively assesses how well the U.S. health system is performing across key indicators of health care outcomes, quality, access, efficiency and equity.[6]   Findings of the National Scorecard indicate that America’s health system falls far short of achievable benchmarks, especially given the resources the nation invests.  The National Scorecard was followed in 2007 with publication of a State Scorecard with data on 32 key indicators that found wide variation across states on access, quality, avoidable hospitalization and costs, equity and healthy lives.

Based on these and other data, the Commission believes that transformation of the U.S. health system is urgently needed to achieve optimal health care for all Americans while improving value for society’s investment in health care.  The State Scorecard offers a framework through which policymakers and other stakeholders can gauge efforts to ensure affordable access to high-quality, efficient and equitable care. With a goal of focusing on opportunities to improve, the analysis assesses performance relative to what is achievable, based on benchmarks drawn from the range of state health system performance.  It indicates that we have much to gain as a nation by aiming higher with a coherent set of national and state policies that respond to the urgent need for action.  The analysis of the range of state performance points to five cross-cutting findings:

• There is wide variation among states - this means that the potential exists for the country to do much
  better.
• Leading states consistently outperform lagging states.  The patterns indicate that federal and state policies and local and regional health systems make a difference.
• Across states, better access is closely associated with better quality.
• There are significant opportunities to reduce costs as well as improve access to and quality of care.  Higher quality is not associated with higher costs across states.
• All states have substantial room to improve.

   

What States Can Do

Health system performance is one of many forces that shape health status and longevity. Whether people live long, healthy and productive lives depends on many factors, including family history, health-related behaviors, poverty, and environmental and workplace hazards.  Education levels and cultural beliefs influence health outcomes and patients’ interactions with the health system. Yet, while underlying poverty levels and demographics matter, strategic state policies—including public health initiatives—can make a difference.  The findings point to the need for action in the following key areas:

• Universal coverage: This is critical for improving quality and delivering cost-effective care, as well as ensuring access.  Federal action, as well as state initiatives, will be essential for progress nationwide.

• More information to assess performance and identify benchmarks.  It takes information to guide and drive change. We need more sophisticated information systems and better information on practices and policies that contribute to high or varying performance.

• Analyses to determine the key factors that contribute to variations.  States can then develop evidence-based strategies for improvement. 

• Collaboration across public and private sectors.  This is essential for coherent, strategic, and ultimately effective improvement efforts.

Benchmarks set by leading states, as well as exemplary models within the United States and other countries, show that there are broad opportunities to improve and achieve better and more affordable health care.  With health costs rising faster than incomes and straining family, business, state and federal budgets, with access deteriorating, and with startling evidence of variable quality and inefficient care, individual states and the nation as a whole have much to gain from aiming higher.  All states can do better; and all should continually ask, “Why not the best?”

Footnotes

^[1] United Health Foundation, America’s Health Rankings: A Call to Action for People and Their Communities, 2007 Edition, Minnetonka, Minnesota: United Health Foundation, 2007.

[2] A. B. Martin, L. Whittle, S. Heffler et al. “Health Spending by State of Residence, 1991-2004,” Health Affairs 26, no. 6 (2007): w651-663.

[3] AHRQ (Agency for Healthcare Research and Quality) National Healthcare Quality Report, 2006. AHRQ Pub. No. 07-0013, Rockville, Md.: U.S. Department of Health and Human Services, 2006.

J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecard on Health System Performance, The Commonwealth Fund Commission on a High Performance Health System, June 2007.

[4] K. Davis, and C. Schoen, “State Health System Performance and State Health Reform,” Health Affairs 26, no. 6 (2007): w664–w666.

[5] K. Davis, “Toward a High Performance Health System: The Commonwealth Fund’s New Commission,” Health Affairs 24, no. 5 (2005), 1356-1360.

[6]  C. Schoen, K. Davis, S. K. H. How, and S. C. Schoenbaum, “U.S. Health System Performance: A National Scorecard,” Health Affairs 25, no. 6 (2006): w457-w475.