Rising to the Challenge RESULTS FROM A SCORECARD ON LOCAL HEALTH SYSTEM PERFORMANCE 2012 THE COMMONWEALTH FUND COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM MARCH 2012 THE COMMONWEALTH FUND COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM Membership David Blumenthal, M.D., M.P.P. Jon M. Kingsdale, Ph.D. Chair of the Commission Consultant Stuart Guterman Samuel O. Thier Professor of Executive Director Medicine and Professor of Health Gregory P. Poulsen, M.B.A. Vice President for Payment Care Policy Massachusetts General Senior Vice President and System Reform Hospital/Partners HealthCare System Intermountain Health Care The Commonwealth Fund and Harvard Medical School Neil R. Powe, M.D., M.P.H., M.B.A. Cathy Schoen, M.S. Maureen Bisognano, M.Sc. Chief, Medical Services Research Director President and Chief Executive Officer San Francisco General Hospital Senior Vice President for Institute for Healthcare Improvement Constance B. Wofsy Distinguished Research and Evaluation Professor and Vice-Chair of Medicine The Commonwealth Fund Sandra Bruce, M.S. University of California, San Francisco President and Chief Executive Officer Resurrection Health Care Louise Y. Probst, R.N., M.B.A. Executive Director Christine K. Cassel, M.D. St. Louis Area Business Health President and Chief Executive Officer Coalition American Board of Internal Medicine and ABIM Foundation Martín J. Sepúlveda, M.D., FACP IBM Fellow and Vice President Michael Chernew, Ph.D. Integrated Health Services Professor IBM Corporation Department of Health Care Policy Harvard Medical School David A. Share, M.D., M.P.H. Vice President John M. Colmers, M.P.H. Value Partnerships Vice President Blue Cross Blue Shield of Michigan Health Care Transformation and Strategic Planning Glenn D. Steele, Jr., M.D., Ph.D. Johns Hopkins Medicine President and Chief Executive Officer Geisinger Health System Patricia Gabow, M.D. Chief Executive Officer Alan R. Weil, J.D., M.P.P. Denver Health Executive Director National Academy for State Health Glenn M. Hackbarth, J.D. Policy Consultant George C. Halvorson Chairman and Chief Executive Officer Kaiser Foundation Health Plan, Inc. THE COMMONWEALTH FUND, among the first private foundations started by a woman philanthropist— Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. COVER PHOTOS Top left: Donnelly Marks. Top right: Karen Campbell. Middle left: Don Tracy. Middle right: Paula Lerner. Bottom left: Fotosearch. Bottom right: Martin Dixon. Rising to the Challenge RESULTS FROM A SCORECARD ON LOCAL HEALTH SYSTEM PERFORMANCE, 2012 David C. Radley, Sabrina K. H. How, Ashley-Kay Fryer, Douglas McCarthy, and Cathy Schoen Prepared for the Commonwealth Fund Commission on a High Performance Health System March 2012 ABSTRACT The first-ever Scorecard on Local Health System Performance provides U.S. communities with comparative data to assess the performance of their health care systems, establish priorities for improvement, and set achievement targets. It tracks 43 indicators spanning four dimensions of health system performance: access, prevention and treatment, costs and potentially avoidable hospital use, and health outcomes. The findings show clearly that where you live matters for health care access and care experiences. Comparing all 306 local health care areas, known as hospital referral regions, in the United States, the report finds that access, quality, costs, and health outcomes all vary significantly from one local community to another, often with a two- to threefold variation in key indicators between leading and lagging communities. The top- performing areas are concentrated in the Upper Midwest and Northeast. Yet, ample opportunities exist for health system improvement in all communities. 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, or of the Commonwealth Fund Commission on a High Performance Health System. 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. 1578. Photo: Donnelly Marks Contents List of Exhibits 4 About the Authors 6 Acknowledgments 7 Preface 8 Executive Summary 9 Introduction 21 Scorecard Methodology 23 Access 24 Prevention and Treatment 33 Potentially Avoidable Hospital Use and Cost 44 Healthy Lives 53 Health System Experience in the Nation’s Largest Metropolitan Areas 62 Poverty, Income, and Geographic Variations in Health System Performance 66 Summary Findings 69 Implications 72 Conclusion 79 Notes 80 Appendices 83 Further Reading 98 List of Exhibits Executive Summary Exhibit 1 Overall Health System Performance Exhibit 2 List of 43 Indicators in Scorecard on Local Health System Performance Exhibit 3 Local Variation: Overall Health System Performance Access Exhibit 4 Overall Performance on Access Dimension Exhibit 5 Percent of Adults Ages 18–64 Uninsured, 2009–2010 Exhibit 6 Percent of Children Ages 0–17 Uninsured, 2009–2010 Exhibit 7 Local Variation: Access Indicators Exhibit 8 Dental Visit in Past Year, 2010: Highest and Lowest Rate Local Areas in Each State Exhibit 9 Performance in the Access and Prevention & Treatment Dimensions Is Related Exhibit 10 Performance of Top and Bottom 10 Percent of Hospital Referral Regions Prevention and Treatment Exhibit 11 Overall Performance on Prevention & Treatment Dimension Exhibit 12 Local Variation: Usual Source of Care and Preventive Care Exhibit 13 Prescription of Potentially Unsafe Medications, 2007 Exhibit 14 Local Variation: Hospital Care Processes and Responsiveness to Patients Exhibit 15 Local Variation: Home Health Quality Indicators Exhibit 16 Nursing Home Pressure Sores and Admission to Hospital from Nursing Homes Exhibit 17 Performance of Top and Bottom 10 Percent of Hospital Referral Regions 4 The Commonwealth Fund Scorecard on Local Health System Performance, 2012 Potentially Avoidable Hospital Use and Cost Exhibit 18 Overall Performance on Potentially Avoidable Hospital Use & Cost Dimension Exhibit 19 Local Variation: Potentially Avoidable Hospital Admissions Exhibit 20 Potentially Avoidable Emergency Department (ED) Use Among Medicare Beneficiaries Exhibit 21 Hospitalizations for Potentially Avoidable Hospital Admissions and 30-Day Readmissions, by Medicare Reimbursement Exhibit 22 Commercially Insured and Medicare Spending per Enrollee, Relative to U.S. Median Spending for Each Population Exhibit 23 Performance of Top and Bottom 10 Percent of Hospital Referral Regions Healthy Lives Exhibit 24 Overall Performance on Healthy Lives Dimension Exhibit 25 Mortality Amenable to Health Care Exhibit 26 Low Birth Weight and Infant Mortality Exhibit 27 Local Variation: Healthy Lives Indicators Exhibit 28 Poor Health-Related Quality of Life and Access Dimension Score Exhibit 29 Performance of Top and Bottom 10 Percent of Hospital Referral Regions Health System Experience in the Nation’s Largest Metropolitan Areas Exhibit 30 The Health System Experience in Select Cities Exhibit 31 Performance on Potentially Avoidable Hospital Use and Cost in the Nation’s Largest Metropolitan Areas Relative to the National Average Poverty, Income, and Geographic Variations in Health System Performance Exhibit 32 Performance Is Lower in Places with a Higher Proportion of Residents Living in Poverty Exhibit 33 Dimension Rankings Among Low-Poverty and High-Poverty Areas Implications Exhibit 34 National Cumulative Impact if All Local Areas Achieved Top 1 Percent of Regional Performance www.commonwealthfund.org 5 About the Authors from Harvard College with a B.A. in a self-designed major, “The Determinants of Population Health,” and a minor in David C. Radley, Ph.D., M.P.H., is senior analyst and health policy. project director for The Commonwealth Fund’s Health Douglas McCarthy, M.B.A., is senior research adviser to System Scorecard and Research Project, a team based at The Commonwealth Fund and the Institute for Healthcare the Institute for Healthcare Improvement in Cambridge, Improvement (IHI) in Cambridge, Mass., where he Mass. Dr. Radley and his team develop national, state, conducts qualitative research on state and local efforts and substate regional analyses on health care system to promote health system transformation. He supports performance and related insurance and care system market The Commonwealth Fund’s Health System Scorecard structure analyses. Previously, he was associate in domestic and Research Project team at IHI. His 25-year career has health policy for Abt Associates, with responsibility for a spanned research, policy, operations, and consulting roles number of projects related to measuring long-term care for government, corporate, academic, and philanthropic quality and evaluating health