Healthcare access, cost, quality and outcomes can vary greatly from one community to the next, both within states and across states, depending on the performance of the healthcare system available to residents, according to a new report from the Commonwealth Fund Commission on a High Performance Health System.
In the first scorecard measuring how 306 local U.S. areas are doing on key healthcare indicators such as insurance coverage, preventive care, and mortality rates, researchers at The Commonwealth Fund found significant differences between the best- and worst-performing localities. Major U.S. cities also showed wide disparities on many key measures of healthcare, with San Francisco and Seattle ranking among the top 75 local areas in the country, and Houston and Miami ranking in the bottom 75. An interactive map accompanying the report allows comparison of cities and communities across the country.
The stark differences in healthcare add up to real lives and dollars. According to the scorecard, 66 million people live in the lowest-performing local areas in the country. If all local areas could do as well as the top performers, 30 million more adults and children would have health insurance, 1.3 million more elderly would receive safe or appropriate medications, and Medicare would save billions of dollars on preventable hospitalizations and readmissions.
The report, "Rising to the Challenge: Results from a Scorecard on Local Health System Performance, 2012," and the online interactive map rank local areas on 43 performance metrics grouped into categories that include access to healthcare, healthcare prevention and treatment, potentially avoidable hospital use and cost and health outcomes. The 43 metrics include potentially preventable deaths before age 75, prevalence of unsafe medication prescribing, the proportion of adults who receive recommended preventive care, and the percentage of uninsured adults.
The report finds there is room to improve everywhere, with no community consistently in the lead on all the factors that were measured. However, there were geographic patterns: Local areas in the Northeast and upper Midwest often ranked at the top, while local areas in the South, particularly the Gulf Coast and southern central states, tended to rank at the bottom on many measures.
“This first local scorecard provides a baseline for how healthcare systems are performing at the local level when it comes to the most essential functions, including whether people can get the healthcare they need, whether they receive timely preventive care and treatment, how healthy they are, and how affordable healthcare is,” said Commonwealth Fund Senior Vice President Cathy Schoen, a coauthor of the report. “The scorecard is a tool for local healthcare leaders and policymakers that allows them to focus on where their healthcare systems fall short, learn from the best-performing areas, and target efforts to improve where they are needed most.”
Wide variations within and among states
The scorecard’s trove of local data reveals significant differences in how the healthcare system performs across the country, with some areas doing two to three times as well as others. The wide variations within and among states include:
- In California, the Santa Rosa area ranks in the top 10 percent of all local areas evaluated in the scorecard, while the Bakersfield area ranks in the bottom 25 percent. In Illinois, Bloomington ranks in the top 25 percent overall while Chicago ranks in the bottom half, pulled down by high rates of people without health insurance, high costs, and high rates of potentially avoidable hospital use.
- In Kentucky, there was a 27-percentage-point difference between the best and worst areas when it came to making sure people with diabetes received tests for managing their disease effectively (61 percent in Covington vs. 34 percent in Lexington).
- In Florida, Illinois, Indiana, and Michigan, there was nearly a 20-percentage-point difference between local areas with the highest and lowest rates of hospitalization of nursing home residents.
- The incidence of unsafe medication prescribing for the elderly was four times higher in Alexandria, La., than in the Bronx and White Plains, New York (44 percent vs. 11 percent).
- The proportion of women and men age 50 or older who received recommended preventive care, including screening for cancer, was more than twice as high in the best-performing area than in the worst-performing area (59 percent in Arlington, Va., vs. 26 percent in Abilene, Texas).
The report also reveals strikingly wide variations in health insurance coverage and premature deaths across the country. The percentage of adults ages 18 to 64 who were uninsured ranged from a low of about 5 percent in several local areas in Massachusetts to more than 50 percent in the two areas in Texas which had the highest uninsured rates in the country. Rates of death before age 75 that could have been prevented with timely and effective healthcare ranged from less than 60 per 100,000 in local areas in Washington and Colorado with the lowest rates to more than 150 per 100,000 in the worst-performing areas of Louisiana, Georgia, Mississippi
There are also wide variations in performance among the nation’s largest cities. Many of the country’s biggest cities ranked highly: Boston, Minneapolis and St. Paul, Sacramento, San Francisco and Seattle all scored in the top 75 areas for overall health system performance. In contrast, Dallas, Houston, Miami, and San Antonio scored in the bottom 75. The scorecard also revealed significant variations among large urban areas on specific measures. For example:
- Only 39 percent of adults in Chicago were up-to-date on preventive care like cancer screenings and flu shots, while in Raleigh, N.C., 54 percent of adults were up-to-date on preventive care.
- Deaths that could be prevented by timely access to the right healthcare ranged from 61 in Minneapolis and 71 per 100,000 people in Boston, to 169 per 100,000 people in Memphis.
- Nearly 33 percent of adults in Los Angeles reported they have poor quality of life because of their health, compared with only 20 percent of adults in St. Paul.
Costs differ widely
Healthcare spending also varied widely across the country. Private insurance spending per person in 2009, adjusted for wage differences, was nearly two-and-a-half times greater in the highest-cost areas—Charleston ($5,068) and Huntington ($5,042) in West Virginia, and Wausau ($4,893) and Marshfield ($4,800) in Wisconsin – than in the lowest-cost areas of Honolulu ($2,014) and the cities of Buffalo ($2,228) and Rochester ($2,319) in New York State.
Medicare spending also varied widely. Average per-person Medicare reimbursements in 2008 ranged from a low of $5,089 in Honolulu to a high of $15,813 in Miami. Overall, Medicare costs tended to be higher in the East and South than in the Midwest and West.
The scorecard authors note that private insurance and Medicare spending patterns are inconsistent. Although there are areas that are relatively high- or low-cost for both Medicare and private insurance, many areas either have relatively high Medicare spending and relatively low commercial spending, or relatively low Medicare spending and relatively high commercial spending. The authors say that the spending inconsistencies point to the need for more comprehensive data on total spending, prices, and cost trends. Such information will be critical in order to address healthcare costs in local communities.
Poverty Linked to Poorer Access to Care, But Community Income Not Always Related to Health System
Overall, the scorecard found that high-poverty communities had poorer access to care and often worse health outcomes. For example, no community with a high poverty rate (more than 20 percent of people living below the federal poverty level) ranked in the top 75 areas on access to healthcare.
However, the socioeconomic status of a community did not always relate to how it performed on the scorecard. The report found significant variations within high- and low-income areas in the measures for prevention and avoidable hospital use and costs, with some low-income communities doing better than might be expected and some high-income communities doing worse. For example, areas with higher levels of poverty, including El Paso, Texas, Durham, N.C., and Columbia, S.C., ranked in the top half of the scorecard on preventable hospital use and costs, while several areas with lower levels of poverty, including Wilmington, Del., Hinsdale, Ill., Ridgewood, N.J., and Dayton Ohio, ranked in the bottom half.
“Where you live in this country largely determines, for better or worse, the kind of healthcare you will receive,” said Commonwealth Fund President Karen Davis. “The wide differences in how well the healthcare system performs in the top- and bottom-performing communities reveal many missed opportunities. We know that local communities can, and must, do better to assure all Americans have the opportunity to live long, healthy lives.”
Performance measures are interrelated
The report finds that across local areas, better access to healthcare was associated with better scores on prevention and treatment measures, which indicates higher-quality healthcare. In addition, better access and timely healthcare were associated with better health and quality of life. Conversely, poor access to healthcare and lower quality of care were associated with higher rates of potentially preventable hospital admissions and higher costs. The authors conclude that the strong links across the healthcare system underscore the need for policymakers and community leaders to take a big-picture view in order to make improvements.
Opportunities to improve
Despite the fact that many states and local areas had pockets of excellent healthcare, there were no regions of the country where every community led on all key areas of care. Sixty-six million people live in the local areas that scored in the bottom 25 percent of the 306 local areas, indicating that even moderate improvements could have a far-reaching, positive effect. If all communities could do as well as the local areas in the top 1 percent of the scorecard:
- More than 30 million additional adults and children would have health insurance, and the number of uninsured would drop by more than half.
- More than 9 million additional adults over age 50 would receive evidence-based preventive care like cancer screenings and immunizations.
- There would be 1.5 million fewer hospitalizations and readmissions to the hospital among chronically ill Medicare patients, people in nursing homes, and people who had recently been in the hospital, saving Medicare billions of dollars.
- 1.3 million fewer Medicare recipients would be given unsafe and inappropriate prescription medication.
“The local scorecard spotlights the opportunities and challenges facing us as we try to achieve better healthcare experiences, better health, and more affordable care,” said Commonwealth Fund Commission on a High Performance Health System Chair David Blumenthal, MD, the Samuel O. Thier Professor of Medicine and Professor of Healthcare Policy at Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School. “Despite the large number of communities that lag relative to leaders, we see places with thriving healthcare systems, providing excellent care at a reasonable cost. The Affordable Care Act provides new resources and the opportunity to innovate in every state and local area. We must commit to working together to raise the bar so every community can do as well as the best among us.”
The report is the work of Commonwealth Fund researchers David Radley, Sabrina How, Ashley-Kay Fryer, Douglas McCarthy, and Cathy Schoen.
The Scorecard on Local Heath System Performance, 2012, tracks 43 performance metrics in each of 306 local healthcare regions across the country. These are defined by hospital referral areas. The scorecard uses the most recent data available for each indicator, generally from 2008–2010, providing a baseline for assessing the impact of national reforms. Health system performance is evaluated in four dimensions:
- Access includes rates of insurance coverage for adults and children and indicators of access and affordability of care.
- Prevention and treatment includes indicators that measure the quality of ambulatory care, hospital care, long-term, post-acute, and end-of-life care.
- Potentially avoidable hospital use and cost includes indicators of hospital care that might have been prevented or reduced with appropriate care and follow-up as well as costs of medical care.
- Healthy lives includes indicators that assess the degree to which people are able to enjoy long and healthy lives