Washington Post, June 13, 2007
Forbes.com,  June 13, 2007 (HealthDay News)

When it comes to health care, U.S. states are, well, all over the map.

A new study finds large disparities in how different states perform in reference to quality of health care, with some states outdoing others by a factor of two or even three.

For instance, premature death rates (before age 75) from conditions that might have been prevented with appropriate medical care were 50 percent lower in states such as Minnesota, Utah, Vermont, Wyoming and Alaska than in the District of Columbia and states with the highest premature death rates -- Tennessee, Arkansas, Louisiana and Mississippi. In the first five states, average death rates were 74.1 per 100,000 people, compared to 141.7 per 100,000 people in the other four states and the District of Columbia.

The new scorecard was issued Wednesday by The Commonwealth Fund, and is the first report to rate states this way.

In 2006, a international scorecard by The Commonwealth Fund found that the U.S. health-care system got a "D" (for dismal) ranking, last among six Western nations in health care, despite spending the most.

This new report drills down to a more local level.

"The states scorecard is closer to home. Where you live really matters in terms of your experience with the American health-care system," Karen Davis, president of The Commonwealth Fund, said at a news conference Tuesday. "The gaps from state to state add up to real lives and real dollars."

If the low-performing states could catch up with their high-achieving counterparts, 90,000 premature deaths (before the age of 75) could be avoided, 22 million additional adults and children would be insured, nearly 9.5 million older adults would receive basic screenings, nearly 4 million diabetics would receive critical annual preventive care, and states would save $22 billion a year in Medicare costs, according to the report.

The report ranked states on 32 indicators grouped into five categories: access, quality, potentially avoidable use of hospitals and costs of care, equity, and ability to live long and healthy lives.

States in the Northeast and Upper Midwest tended to rank higher in multiple categories. States with the lowest scores tended to be in the South.

The same states that did well on access to care also did well on quality of care. Four of the five top states in access to care (Massachusetts, Iowa, Rhode Island and Maine) were also among the highest on quality of care. States with low-quality rankings tended to have high rates of uninsured residents.

The top five states overall were Hawaii, Iowa, New Hampshire, Vermont and Maine, all of which have high rates of health insurance -- nearly 90 percent of working-age adults.

By contrast, in the five lowest-ranged states -- Nevada, Arkansas, Texas, Mississippi and Oklahoma -- only 70 percent to 78 percent of adults are insured.

"The leading states outperformed the lagging states in multiple areas and dimensions in overall rankings," said Cathy Schoen, senior vice president at The Commonwealth Fund. "The bottom 10 tend to rank low on multiple indicators and areas of the scorecard, indicating systemic differences in policies and practices underlie these variations."

High spending levels did not necessarily correlate with high quality health care. In fact, the top spending states tended to have higher rates of hospitalizations for diabetes, asthma and other chronic illnesses, which can be effectively treated on an outpatient basis.

Among the report's other findings:

• The percent of adults under 65 years who lacked health insurance in 2004-05 ranged from a low of 11 percent in Minnesota to a high of 30 percent in Texas. The percent of uninsured children ranged from 5 percent in Vermont to 20 percent in Texas.
• All states showed room for improvement in quality of care. The percent of adults aged 50 or older receiving all recommended preventive care ranged from a high of 50 percent in Minnesota to a low of 33 percent in Idaho. Childhood immunization rates varied from 94 percent in Massachusetts to less than 75 percent in the bottom five states.
• Rates of potentially preventable hospital admissions among Medicare beneficiaries ranged from more than 10,000 per 100,000 beneficiaries in the five states with the highest rates to less than 5,000 per 100,000 in the five with the lowest rates -- Hawaii, Utah, Washington, Alaska and Oregon.

Several outside experts said the scorecard offers some valuable insights that could serve as a road map to better health care in the United States.

"I thought the Commonwealth report was wonderful, and underscored the importance of looking at what leadership can do at the state level to inform multiple debates about improving access, quality and lowering costs all at the same time," said Cathy Dunham, president of the Access Project in Boston. "It's really an important and somewhat jarring reminder of the disparities between states, as well as between regions."

John R. Graham, director of health-care studies at the Pacific Research Institute in San Francisco, said, "This Commonwealth Fund report confirms that more spending does not result in better care. We can learn a lot from these measurements."

"However, the Commonwealth Fund's authors are nearsighted when it comes to reform. They recommend more government action. However, their own and other evidence indicates that government control does not result in uniform quality of care. Much evidence indicates that Medicare spending and quality is higgledy-piggledy around the country, and Medicare is arguably the most centralized government health-care plan in the world. Instead, reducing government intrusion into people's health care, while not guaranteed to result in uniform quality of care, will increase the likelihood of people making healthier decisions."

More information

For more on the report, visit The Commonwealth Fund.

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