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

Performance
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.

Methodology
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