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.