States building high-performance health systems, but much more can be done
States building high-performance health systems, but much more can be done
States are pursuing health system improvements across the full spectrum of their authority, including health care purchasing, provider regulation, performance data reporting, integration of public health with health care approaches, and improving the availability and affordability of health insurance. But for as much as states are doing, a National Academy for State Health Policy (NASHP) study finds there is room for states to do much more. It says ongoing efforts to track, study, and diffuse information on state activities could accelerate adoption of promising policies and practices.
NASHP reported findings from its Commonwealth Fund-supported State Health Policies Aimed at Promoting Excellent Systems (SHAPES) project. The project was aimed at identifying and spreading information about state health policies and practices for promoting high-performance health systems. NASHP senior program director Catherine Hess tells State Health Watch states have an opportunity to try some things and can show the way to health care reform, but can't do it all without some federal help, and especially federal money.
"It would benefit states to go through this report and look at what they are doing in these areas," she says. "I think most states could find areas in which they could do more."
States, Ms. Hess says, have been doing the most in the area where historically they have been involvedimproving coverage so as to improve access to careprimarily because of the federal-state Medicaid partnership. States also have been working on quality, Ms. Hess tells State Health Watch, but that has been a more recent and growing focus. Many of the new tools being used, she says, have been developed in the private sector and states could benefit by partnering in that arena. While states have been taking some action to leverage their buying power, Ms. Hess says they could do more, especially in terms of looking at all places where they purchase care. "Purchasing is another way to carry out the state role in access and quality," she says.
IT interest growing
States have not been as active in the information technology area, according to Ms. Hess, although she sees that interest growing. Information technology, she says, needs strong private sector engagement and federal tie-ins at the regional level. "You need federal involvement if you want to have regional IT systems," Ms. Hess says.
Asked why it seems there is less emphasis on patient safety, when so much was said about it several years ago, Ms. Hess says while the study authors reported there was relatively less going on in late 2006 when the survey was taken, there has been a significant increase in safety activity recently.
The report points out the need for states to exchange information and experiences. Ms. Hess says such exchange does happen but it is somewhat uneven, again reflecting financial resources. "Information exchanges work better if there is an outside organization that maintains support for convening groups and organizing the sharing through political cycles," she says. "When there is such support, it often is short-lived. The problem is that the support that comes is often sporadic and topic-specific. It would be great if it could be more sustained and with a broader focus."
Take-home points
Study authors said their analysis found significant variation in states' involvement in system improvements, including the following broad categories:
- Health insurance coverage. States are said to be able to play a major role in ensuring affordable health coverage, not only by maximizing use of federal programs, but by going beyond them with state-only investments and public-private approaches. Federal financial support is most available for children, and many states are working to extend that support to cover all children. The study also found that states are working to cover adults. States are exerting their influence over insurance benefit design by defining minimum benefit packages and requiring parity in mental health coverage.
- Quality, safety, and value. States reportedly are engaging in collaborative efforts to improve quality of care, both with the private sector and in cross-agency efforts. They are using a variety of levers as purchasers, including requiring reporting on quality, employing specific contractual provisions for vulnerable populations, and having joint quality requirements in multiple-agency purchasing.
- Health system infrastructure. More than half of responding public health agencies and governors' offices reported that their states have a public health information system that integrates data from multiple sources. Immunization and vital statistics data were most commonly included in these systems, following by hearing screenings, laboratory data, newborn screenings, hospital discharge information, and cancer registry data. States are addressing health system provider capacity by monitoring the safety net, addressing provider shortages, and reimbursing for telehealth. A number of states cited collaborative relationships with other entities in these efforts, including primary care associations representing community health centers.
NASHP says every state reported activity to promote achievement of a high performance health system. Even though this finding was not unexpected, it underscores the fact that states are today important players with multiple roles in achieving improved health system performance.
Promoting more equal access
All states are playing a role in promoting more equal access to the health care system. More than 80% of states cover children at income levels that meet or exceed federal program minimums. And some states are blazing trails in promising coverage for all children. Some states also are moving to ensure that everyone, including adults, has affordable coverage. States are simplifying administrative processes and beginning to make greater use of technology for application, enrollment, renewal, and coordination of coverage, as well as for other services.
Some states also are trying to exert influence with the private insurance market, leverage their purchasing power, and collaborate more with the private sector. While historically these have been areas of concern to the federal government or private sector, states now are taking a much more active role. Thus, more than half the responding states said they require minimum benefit packages for the individual or small group market. Most states have programs to reduce the cost of coverage for small employers and their workers. And states are taking advantage of their relatively new role as purchasers of health care coverage for a substantial share of the population to influence the content and quality of care.
Most states report considering quality when making contracting decisions and requiring reporting on quality measures. States are maintaining their focus on the needs of racially and ethnically diverse populations, as well as vulnerable populations such as children and those with disabilities, increasingly through contractual obligations. And in addition to serving as regulators and purchasers in the private sector, states also are partnering and collaborating in areas relevant to system performance.
Interestingly, fewer states are actively pursuing system performance in areas such as efficiency and patient safety. NASHP says those findings may reflect the lack of a clear federal framework for action, the recent emergence of these issues relative to topics such as insurance coverage, or a belief that federal action will supersede state roles.
Much remains to be done
While NASHP found considerable state activity under way geared toward creating a high-performance health system, there still is much more that can be done. Although there are very real fiscal constraints regarding coverage in the absence of strong federal action, the report says, many states could work to bring coverage levels to that of their peers in other states by increasing federally matched program eligibility levels and by simplifying and automating enrollment and renewal processes. The analysts say more states could use regulatory levers to influence the private marketplace to provide affordable products with adequate benefit packages. And many states and agencies could increase their attention to contract quality provisions, especially those addressing the specific needs of children, diverse racial and ethnic groups, and individuals with special health care needs.
The report found that state employee health plans generally lag behind Medicaid and SCHIP agencies in using purchasing levers to affect content and quality of care. And it said more states could monitor and address the strength of the health care safety net.
The level of state activity could be improved through ongoing mechanisms to monitor, study, and report state activities. While some of the policies and practices reported by states, particularly those related to public coverage, are monitored and reported regularly by national organizations including NASHP, many are not. So as states look to other states for advice and ideas, it will be important to have a source of current information on activities and outcomes to facilitate learning and adoption of proven and promising policies and practices. The analysts said their survey "laid important groundwork in identifying relevant state policies and practices. In the future, a mechanism that obtains similar, updated information from surveillance of state activity could help states move toward better performance."
In-depth analysis would help
There is more analysis that can be done as well. The SHAPES survey only touched the surface of a broad range of state policies and practices, the analysts say. More in-depth exploration is likely to yield additional information that might prove useful to understanding impact and to accelerating diffusion. Areas that appeared particularly ripe for further exploration, according to the report, included assisting small employers with affordable coverage, developing minimum benefit packages for the private market or public programs, and developing and maintaining interagency and public-private collaboration and forums. Other areas to pursue include using purchasing levers to address patient safety, revising policies and providing incentives for health information exchange and technology, and integrating population-based and health care system strategies to achieve improved health outcomes.
Download the report at www.commonwealthfund.org/publications/publications_show.htm?doc_id=676496. Contact Ms. Hess at (202) 903-2783.
States are pursuing health system improvements across the full spectrum of their authority, including health care purchasing, provider regulation, performance data reporting, integration of public health with health care approaches, and improving the availability and affordability of health insurance.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.