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Rising to the Challenge: Results from a Scorecard on Local Health System Performance, 2012 David Radley and Cathy Schoen On behalf of the Commonwealth Fund Commission on a High Performance Health System www.commonwealthfund.org March 13, 2012 Embargoed: Not for release before 12:01 ET Wednesday, March 14, 2012 2 2012 Local Scorecard: Key Findings • Where you live Matters – Wide variation across 306 local areas on access, care, outcomes, and costs – Two to three-fold variations on many key indicators – Often wide variation between communities in the same state – Leaders offer benchmarks and targets to improve • Strong geographic patterns – Leading areas often in the Northeast and Upper Mid-West – Regional patterns vary by dimension • Dimensions of health system performance are interrelated – Access, care and healthy lives correlated across communities – Prevention and treatment related to avoidable costs • Opportunities for all communities to improve – No local area consistently leads all key indicators – Potential gains in health, care experiences and lower costs with strategic local action, supported by national reforms 3 Overall Health System Performance SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 4 2012 Local Scorecard Summary of Health System Performance Avoidable Top Quartile 2nd Quartile 3rd Quartile Bottom Quartile Missing Data Bottom Performing HRRs Top Performing HRRs 1 2 3 4 Overall Population Rank Count 1 St. Paul, MN 1,077,980 2 Dubuque, IA 154,083 3 Rochester, MN 418,800 4 Minneapolis, MN 3,237,168 5 Appleton, WI 333,220 6 Santa Rosa, CA 488,469 7 La Crosse, WI 350,219 7 St. Cloud, MN 260,500 9 Manchester, NH 893,654 9 San Mateo County, CA 820,908 11 Cedar Rapids, IA 299,158 12 Green Bay, WI 510,108 12 Lancaster, PA 666,199 294 295 295 297 298 298 300 301 301 303 304 304 306 Lexington, KY Florence, SC Tupelo, MS Meridian, MS Oklahoma City, OK Shreveport, LA Jackson, MS Alexandria, LA Texarkana, AR Beaumont, TX Hattiesburg, MS Oxford, MS Monroe, LA 1,518,597 359,716 394,380 201,585 1,879,596 700,013 1,070,263 292,937 261,650 464,624 316,829 152,428 270,188 Prevention Hospital & Treatment Use & Cost Access Healthy Lives 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 4 4 4 3 4 4 4 4 4 3 4 3 4 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Access 5 Percent of Adults Ages 18-64 Uninsured, 2009-2010 HRR = hospital referral region DATA: U.S. Census Bureau, 2009-10 American Community Survey SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Access Percent of Children Ages 0-17 Uninsured, 2009-2010 HRR = hospital referral region DATA: U.S. Census Bureau, 2009-10 American Community Survey SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 6 Access 7 Prevention and Treatment Score Better Access is Associated with Better Prevention & Treatment Access Score SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Access 8 Better Access is Associated with Better Prevention & Treatment Overall Performance on Access Overall Performance on Prevention & Treatment SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Prevention & Treatment 9 Performance Varies Among Top-Ranked Local Areas in Prevention & Treatment 1 2 3 4 Top Quartile 2nd Quartile 3rd Quartile Bottom Quartile Missing Data Dimension Rank 1 1 3 3 3 3 3 3 3 10 10 10 10 14 14 14 14 14 14 14 Local Area Manchester, NH Wausau, WI Bangor, ME Boston, MA Cedar Rapids, IA Lancaster, PA Neenah, WI Portland, ME Worcester, MA Appleton, WI Arlington, VA Dubuque, IA Rochester, MN Boulder, CO Grand Rapids, MI Lebanon, NH Marshfield, WI Mason City, IA St. Cloud, MN Traverse City, MI Adult Usual Adult Diabetic InapproSource of Preventive Preventive priate Care Care Care Prescribing 1 2 1 1 2 1 2 1 1 1 3 3 3 3 1 1 3 1 3 1 1 1 1 1 2 2 1 1 1 2 1 1 1 2 1 1 3 2 1 1 1 0 1 1 1 2 1 1 1 1 1 0 1 0 2 1 1 0 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 2 1 1 1 1 2 Hospital 30day Mortality Hospital Quality 1 1 1 2 1 2 3 1 2 1 2 3 4 3 1 3 2 2 4 1 4 3 2 1 1 1 2 2 1 4 1 3 1 2 3 3 3 4 1 1 Patient Hospital Discharge Care Instructions Experience 1 2 1 2 2 4 1 1 4 1 4 1 1 1 1 1 1 2 1 1 SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 2 1 Home Health Quality Nursing Home Quality 3 2 1 2 4 3 4 1 3 4 1 3 4 4 3 3 3 4 4 3 Late or no hospice 1 1 1 1 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 3 2 2 4 3 1 1 1 4 3 1 1 1 3 1 1 4 3 1 4 2 Prevention & Treatment 10 Usual Source of Care and Preventive Care Percent Best HRR 100 93 Top 90th %ile Median Bottom 10th %ile Worst HRR 89 82 74 69 59 59 56 51 50 45 44 38 37 26 0 Adults with a usual source of care Adults age 50+ received recommended screening and preventive care 27 Adult diabetics received three recommended diabetes services HRR = hospital referral region DATA: Adults with usual source of care—2009-10 BRFSS; Adults received preventive care—2008 & 2010 BRFSS; Adult diabetic recommended care—2008-10 BRFSS SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Prevention & Treatment Prescription of Potentially Unsafe Medications, Medicare Beneficiaries 2007 HRR = hospital referral region DATA: 2007 Medicare Part D 5% Data. Beneficiaries who received at least one drug that should be avoided for the elderly. SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 11 Prevention & Treatment 12 Hospital Clinical Care and Responsiveness to Patients Percent Best HRR 100 100 98 95 Top 90th %ile 99 90 97 96 Median 94 88 77 Bottom 10th %ile 89 86 83 79 Worst HRR 74 71 67 63 59 53 50 0 Patients hospitalized for heart failure who received recommended care Surgical patients received Patients given information appropriate care to prevent about what to do during their complications recovery at home HRR = hospital referral region DATA: 2010 CMS Hospital Compare SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Hospital staff always managed pain well, responded when needed help, and explained medicines Prevention & Treatment 13 High-risk nursing home residents with pressure sores (%) Nursing Home Pressure Sores and Admission to Hospital from Nursing Homes Long-stay nursing home residents with a hospital admission (%) HRR = hospital referral region DATA: Residents with pressure sores—2008-09 MDS; Residents with hospital admission—2008 MEDPAR, MDS SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Potentially Avoidable Hospital Use & Cost Overall Performance on Potentially Avoidable Hospital Use & Cost SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 14 Potentially Avoidable Hospital Use & Cost 15 Potentially Avoidable Hospital Admissions Percent Best HRR Top 10th %ile Median Bottom 90th %ile Worst HRR 50 47 37 32 28 27 25 25 22 20 20 18 19 15 12 12 6 0 Readmissions within 30 days of discharge as percent of all admissions among Medicare beneficiaries Long-stay nursing home residents hospitalized within 6-month period Home health care patients with a hospital admission HRR = hospital referral region DATA: Readmissions within 30 days of discharge—2008 Medicare claims as reported by IOM; long-stay nursing home residents hospitalized— 2008 MEDPAR, MDS; Home health care patients with hospital admission—2010-11 OASIS as reported by CMS Home Health Compare. SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Potentially Avoidable Hospital Use & Cost Potentially Avoidable Emergency Department (ED) Use Among Medicare Beneficiaries All ED Visits All Other ER Visits 67% Emergent, but Primary Care Treatable 20% NonEmergent 13% Potentially Avoidable ED Visits HRR = hospital referral region DATA: 2009 5% Medicare SAF NOTE: Potentially avoidable emergency department (ED) visits are considered either non-emergent, where treatment was not required within 12 hours, or emergent but primary care treatable, where care was needed within 12 hours, but the service provided in the ED could have been provided in a primary care setting. SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 16 Potentially Avoidable Hospital Use & Cost 17 Commercially Insured and Medicare Spending per Enrollee, Relative to U.S. Median Spending for each population HRR = hospital referral region DATA: Commercial – 2009 Thomson Reuters MarketScan Database, analysis by M.Chernew, Harvard Medical School. Medicare – 2008 Medicare claims as reported by IOM . Ratio lower than 1.0 indicate percent lower than average; ratio higher than 1.0 indicate percent higher than average. Median spending determined separately for the commercially insured and Medicare populations SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Healthy Lives 18 Mortality Potentially Preventable by Health Care Deaths per 100,000 Population, 2005‒2007 All Races White Race HRR = hospital referral region DATA: 2005-07 Vital statistics. Age-standardized death rates before age 75 for causes potentially preventable with timely effective care, including ischemic heart disease, diabetes, stroke, bacterial infections and screenable cancers. SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Healthy Lives 19 Healthy Lives Indicators Percent Best HRR Top 10th %ile Median Bottom 90th %ile Worst HRR 60 46 42 40 36 36 31 30 24 24 24 19 20 13 16 15 3 Adults who smoke 18 10 6 0 30 28 6 Adults ages 18-64 who are Adults ages 18–64 who have Adults who report fair/poor obese lost 6+ teeth due to tooth health status, 14 or more bad mental health days, or who decay, infection, or gum have health-related activity disease limitations HRR = hospital referral region DATA: 2009-10 BRFSS SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 Healthy Lives 20 People who report fair/poor health healthrelated activity limitations (%) Better Access is Associated with fewer Adults Reporting Poor Health or Health-Related Limitations Access Score HRR = hospital referral region DATA: Adults Reporting Poor Health or Health-Related Limitations 2009-10 BRFSS SOURCE: Commonwealth Fund Local Scorecard on Health System Performance, 2012 21 Poverty and Health System Performance • High-poverty rates associated with worse access, lower rates of preventive care and poor health – Better access should improve care, lives and health system performance for communities • Income not always predictive of performance – Some low-income communities perform better than expected – Some high-income communities perform worse than expected on care, costs and healthy lives • Link between income weakest for two dimensions: – Prevention and Treatment – Potentially Avoidable Hospital Use & Cost National Gains if All Local Areas Achieved Top Rates of Performance • More people insured and with a primary care source: – 30 million more adults and children insured – 25 million more adults with a usual source of primary care • More receive recommended preventive care: – 9.4 million adults age 50+ would receive evidence-based preventive care, including cancer screenings and immunizations. • Less avoidable hospital use: – 1.4 million fewer Medicare hospital admissions and readmissions per year; potential savings of over $8 billion a year • Safer use of prescriptions drugs: – 1.3 million fewer Medicare beneficiaries would receive a potentially unsafe or inappropriate prescription 22 23 Summary and Implications • Substantial opportunity to improve – 66 million people live in lowest performing areas; 156 million live in areas that perform below average – Scorecard offers starting point to compare and inform strategic action to improve – Within state variation points to potential of targeted action • Affordable Care Act provides new resources and tools to support states and communities – Access is foundation for care and healthier lives – Preventive care, payment and information resources – Opportunity to innovate; New State Authority • Rising to the Challenge – Cost pressures ever more urgent to take action to improve – Local providers and community leaders have potential to improve care, health and costs performance 24 Rising to the Challenge: Results from a Scorecard on Local Health System Performance, 2012 • Co-Authors – David Radley, Sabrina K.H. How, Ashley-Kay Fryer, Douglas McCarthy, and Cathy Schoen • Released: March 13, 2012 • http://www.commonwealthfund.org/Maps-andData/State-Data-Center/Local-Scorecard.aspx – Profiles for all Local Areas – Maps for each of 43 indicators – Interactive benchmarking tools For More Information Visit the Fund’s Web site at www.commonwealthfund.org 25 26 Local Health System Scorecard Methods • Goal: to stimulate discussion and collaboration and inform national, state and local action • Framework modeled on National and State Scorecards – 4 dimensions: access; prevention and treatment; avoidable hospital use and costs; and healthy lives – 43 indicators; national data generally 2008-2010 • National data sources that use same definition and year for each indicator in all 306 local areas – Local areas defined by referral patterns (Hospital Referral Region) rather than city or county political boundaries • Scoring – Each indicator scored as ratio to the top 1%ile – Dimensions Rank = average of indicator scores, then ranked – Overall Rank = average of 4 dimension ranks