In a new Commonwealth Fund report card, the five top-ranked states for overall health system performance were Massachusetts, Hawaii, New Hampshire, Rhode Island, and Vermont. Arkansas, Texas, Oklahoma, West Virginia, and Mississippi were the lowest-ranked states.
The Commonwealth Fund’s 2023 Scorecard on State Health System Performance evaluates 58 healthcare indicators as well as income- and race- and ethnicity-based differences in performance within states. Findings are based on the authors’ analysis of the most recent publicly available data from federal agencies including the U.S. Census Bureau, the Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services, as well as other data sources.
All states experienced large increases in avoidable deaths from 2019 to 2021, due mostly to the COVID-19 pandemic. Several states, however, stood out: Rates in Louisiana, Mississippi, Texas, and New Mexico surged more than 35 percent, while Arizona’s rate rose by 45 percent, the largest increase. Black and American Indian/Alaska Native people, two of the groups most affected by COVID-19, experienced some of the highest rates of avoidable mortality in many states.
In a press briefing, several reporters asked Commonwealth Fund executives to provide some context about why their states scored so low on issues such as maternal health, avoidable emergency department visits and avoidable hospitalizations. The responses highlighted the need for health equity, work force, and primary care infrastructure improvements.
For instance, a reporter from Mississippi sought some perspective on why his state ranks 50th in women's health and reproductive care and what it could do to improve.
Laurie C. Zephyrin, M.D., study co-author and Commonwealth Fund senior vice president for advancing health equity, said that there are a number of possible interventions.
“If we look at the data in terms of what works around addressing maternal mortality and maternal morbidity, there are obviously key interventions that can happen within the healthcare system that integrate quality and equity at the same time, which is really critical,” she said. “We also have to invest in the maternal health care workforce. Some of our prior work shows the impact of decreased investments in, for example, midwives and midwifery care, even decreased access to OB/GYN providers. We have these maternity care deserts. What will it take in terms of investing in a maternal health care workforce? That's something that's going to take planning over the short- and long-term in terms of training for midwifery care, investing in doulas, because we know doulas are really critical to the workforce, community health workers, and really thinking about the workforce capacity needs.
“Ultimately, as we think about any intervention, we truly have to center equity,” Zephyrin said. “When we design a healthcare system that focuses on people that are most marginalized, that improves healthcare delivery and outcomes for all, so any intervention really has to think about who were the worst impacted, who's suffering the most, what parts of the state have the worst impacts and designing interventions that can be tailored to those communities is going to be really critical.”
A reporter from Minnesota asked about why the state scores so low on avoidable ED visits.
David Radley, Ph.D., senior scientist, tracking health system performance, for the Commonwealth Fund, responded that the answer is in part that it is a feature of the way the healthcare system is built in Minnesota. It's a fairly rural state outside of the Twin Cities area and in rural communities, a lot of times the ER is the first line of care. “We want to try to encourage a healthcare delivery system that's more framed around primary care,” he said. “Higher rates of potentially avoidable ED visits signal an inefficient use of healthcare resources. With this measure, the things that we're calling avoidable are primarily things that can be safely treated in an outpatient setting, yet people are going to the emergency room, maybe because it's the only place they have to go, but they're going to the emergency room, which is a more expensive place to receive care.”
Joseph Betancourt, M.D., the Commonwealth Fund’s president, weighed in. “As a primary care doctor, certainly what we've seen over the last few years is a real access issue. States can do very well by way of coverage, but there's a big gap between coverage and meaningful access, which is being able to get your needs met for primary care-sensitive issues,” he said. “They could range from things like a urinary tract infection or asthma exacerbation to cellulitis that could very easily be treated in the outpatient setting. But fundamentally patients who don't have that access, or may not understand these levels of urgency end up in the emergency department. It's really important here not to blame patients for making poor choices. This is really more a marker of where are their shortcomings in access in a timely fashion to conditions that can be managed in primary care and don't necessarily need to be managed in the emergency department. At the Commonwealth Fund, we are very, very interested in the primary care shortage, primary care workforce, primary care reimbursement — how this all ties into many of the issues we've talked about such as behavioral health and the like. It is really another essential area of focus and deserves attention going forward.”
A reporter from Illinois asked a similar question about its low ranking for avoidable hospitalizations.
Radley noted that some of the things said with regard to Minnesota are showing up in Illinois as well. The state ranks high for hospitalizations for conditions that reflect acute exacerbations of chronic illnesses that are not being managed well. Illinois has a high rate of 30-day readmission rates to the hospital and high rates of skilled nursing facility patients having to go to the hospital. “Those things together all reflect opportunities where you could intervene with good primary care, even good specialty care in the case of some of these chronic conditions, to help manage the disease as well and keep people out of the hospital,” he said.
It's a cascade of a situation or condition that emerges in the outpatient setting that if not managed well, the patient ends up in the emergency department and oftentimes, because that condition is a little further on, ends up in a hospitalization, Betancourt added. “This does become about that meaningful access in the primary care setting. I have real concerns about the future in this space, for a couple of reasons. One, when we think about the primary care workforce and workforce issues in healthcare, in general, we see a fair number of primary care doctors due to burnout and demoralization dropping out of the workforce,” he said. “That will likely make this problem worse. We have challenges around reimbursement, and individuals who come out of medical school and residency who choose not to go into primary care due to financial burden, loans and the like, with the reimbursement rate really driving their career decisions. Fundamentally, I think a lot of these discussions around avoidable emergency department use and avoidable hospitalizations point us to the need to create meaningful access and invest in in primary care — both the workforce as well as issues such as reimbursement that drive career choices, and also career choices around people dropping out due to increasing administrative burden.”