STATES’ ROLES IN SHAPING HIGH PERFORMANCE HEALTH SYSTEMS Catherine Hess, Sonya Schwartz, Jill Rosenthal, Andrew Snyder, and Alan Weil National Academy for State Health Policy April 2008 ABSTRACT: States shape the health system in many ways, influencing key components such as insurance coverage, quality of care, and information and provider infrastructures. This report presents findings from the State Health Policies Aimed at Promoting Excellent Systems project, undertaken by the National Academy for State Health Policy, with support from The Commonwealth Fund. After conducting surveys of multiple agencies in states across the country, as well as a review of related literature, this study found that states are pursuing system improvements across the full spectrum of their authority, including health care purchasing, regulation of providers, reporting of performance data, integration of public health with health care approaches, and improving the availability and affordability of health insurance. Despite this activity, this study finds room for states to do much more. Ongoing efforts to track, study and diffuse information on state activities could accelerate adoption of promising policies and practices. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. This and other Fund publications are available online at www.commonwealthfund.org. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1115. CONTENTS About the Authors.............................................................................................................. iv Acknowledgments.............................................................................................................. vi Executive Summary.......................................................................................................... vii Introduction..........................................................................................................................1 Health Insurance Coverage..................................................................................................2 Ensuring Affordable Coverage ......................................................................................2 Streamlining Enrollment and Renewal ..........................................................................7 Designing Benefit Packages ..........................................................................................9 Quality, Safety, and Value.................................................................................................11 Collaborating to Improve Quality of Care...................................................................12 Publicly Reporting Performance Data .........................................................................13 Value-Based Purchasing ..............................................................................................15 Health System Infrastructure .............................................................................................19 Addressing Health System Provider Capacity.............................................................19 Building Information Systems .....................................................................................22 Integrating Health Care and Population-Based Public Health Systems ......................26 Conclusion .........................................................................................................................27 Notes ..................................................................................................................................31 LIST OF FIGURES Figure 1 States’ Policies to Reduce Costs for Small Employers......................................5 Figure 2 Percent of Children Ages 0–17 Uninsured by State ..........................................6 Figure 3 States with Online Medicaid or SCHIP Applications........................................9 Figure 4 States Covering Adult Dental Services in Medicaid, 2005..............................10 Figure 5 Agencies Reporting Purchasing Requirements for Children’s Preventive Services ..................................................................18 Figure 6 Data Included in Integrated Public Health Information Systems ....................23 Figure 7 Use of Integrated Public Health Information Systems ....................................23 iii ABOUT THE AUTHORS Catherine Hess, M.S.W., is a senior program director with the National Academy for State Health Policy (NASHP), where she leads program development and implementation in high performance health systems, community health safety nets, and children’s health coverage. Prior to joining NASHP, Ms. Hess served as an independent consultant to state and federal health agencies and national organizations, and was the first executive director of the national Association of Maternal and Child Health Programs. She has written and spoken extensively on state health policy, particularly health and health care for women, children, youth and families. She holds appointments at the schools of public health at Johns Hopkins University and George Washington University. She has a master of social work degree from Boston University. Sonya Schwartz, J.D., is a program manager at NASHP. She analyzes state policies and practices regarding health insurance coverage, focusing primarily on Medicaid, access to health insurance for the uninsured, and the private health insurance market. Before joining NASHP, Ms. Schwartz was a senior health policy analyst at Families USA, a national, nonprofit organization working to ensure quality health care for all Americans. Ms. Schwartz also served as a National Association of Public Interest Law Fellow at the Food Research and Action Center, a national anti-hunger organization, and also provided legal services to individuals with HIV and AIDS in Los Angeles. Ms. Schwartz received a J.D. from the UCLA School of Law, Public Interest Law and Policy Program. Jill Rosenthal, M.P.H., is a program director at NASHP, where she analyzes policies, provides technical assistance to states, and manages programs on emerging state health policy issues. She focuses primarily on patient safety, and has served on safety-related committees for the Institute of Medicine and the National Quality Forum. She has written extensively on state initiatives to address medical errors and patient safety, as well as children’s health. Ms. Rosenthal has a master’s degree in public health from the University of North Carolina at Chapel Hill. Andrew Snyder, M.P.A., is a policy specialist at NASHP. His work focuses on coverage and benefit design in Medicaid, with a focus on oral health policy issues. Prior to joining NASHP, he managed the dental and vision benefits for Wisconsin Medicaid. While there, he staffed a Governor’s Task Force on Access to Dental Care, and assisted in the design of a Web-based, information-exchange tool to help Milwaukee-area hospitals reduce unnecessary duplication of emergency room services. He has a master’s degree in public affairs from the University of Wisconsin–Madison. iv Alan Weil, J.D., M.P.P., is NASHP’s executive director. Mr. Weil previously served as director of the Assessing the New Federalism project at the Urban Institute, held a cabinet position as executive director of the Colorado Department of Health Care Policy and Financing, and was health policy advisor to Colorado Governor Roy Romer. He also served as assistant general counsel in the Massachusetts Department of Medical Security. Mr. Weil was an appointed member of President Clinton’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. He currently is a member of the Commonwealth Fund Commission on a High Performance Health System, as well as the Kaiser Commission on Medicaid and the Uninsured. He has written extensively, and is the editor of two books. Mr. Weil received his M.P.P. degree from the John F. Kennedy School of Government at Harvard University and his J.D. from Harvard Law School. Editorial support was provided by Deborah Lorber. v ACKNOWLEDGMENTS The authors would like to express their appreciation first and foremost to the state officials who contributed to this report by responding to surveys. We know the heavy demands placed on state officials’ time, and hope this report provides some useful ideas drawn from colleagues in other states. We also want to thank Annette James, a research assistant at NASHP through most of this project, who made substantial contributions in creating, fielding, tracking and following up on the survey instruments, entering data and creating tables for analysis, and contributing her ideas in shaping the project. Alice Lam, a Presidential Management Fellow, contributed extensively to the initial background research and design of the project. Neva Kaye, a NASHP senior program director, provided helpful suggestions and comments during the project. NASHP research assistant Ann Cullen assisted in creating graphs and formatting the report. Elizabeth Osius, also a NASHP research assistant, provided helpful review and editing in the final drafting stages. Four members of the Commonwealth Fund Commission on a High Performance Health System and one additional expert, Dr. Joseph Thompson, the Arkansas Surgeon General, served