Scorecard shows location more critial than income

For healthcare consumers, low household income need not condemn them to low quality, but high income is not the panacea either. A state scorecard released in September by the Commonwealth Fund indicates that the wide differences in healthcare experiences found in a state-by-state comparison often put higher-income as well as low-income families at risk.

It all depends on where you live, according to study authors.

“Lack of insurance is probably one factor, and therefore, implementation of the Affordable Care Act can help to alleviate these differences,” says David Blumenthal, MD, president of the Commonwealth Fund.

The report finds that higher-income people living in states with poor ratings on quality and access are often worse off than low-income people in states that rank at the top of the scorecard.

For example, low-income Medicare beneficiaries in top-ranking Connecticut and Wisconsin are less likely to receive medications that are known to cause health risk than are higher-income elderly in Mississippi, Louisiana and Alabama.

On most indicators, the experiences of low-income individuals in top-performing states ex­ceeded the national average for all incomes, according to the report.

“Where low income individuals have insurance, they look more like their high-income counterparts,” says Cathy Schoen, senior vice president. “Insurance begins to close the income gap.”

Schoen says that the low-income group represents as much as 50% of the  population in states such as Louisiana, Arkansas and New Mexico-three of the lowest-ranking states in the scorecard. With such a high share of the population at risk, even small gains would potentially lower costs of healthcare, according to authors. For high-poverty states, federal resources to expand coverage and invest in local health systems offer significant new opportunities to improve under the Patient Protection and Affordable Care Act (PPACA).

She says the potential gain if all the states rose to benchmark levels could amount to millions of lives, but each state needs to conduct a deeper analysis to find the opportunities to improve.

And Schoen says all states have room to improve, even top-ranked Wisconsin. The organization measured 30 indicators of access, prevention and quality, potentially avoidable hospital use and health outcomes, and no state was in the top quartile for all 30. In fact, nine of the 10 top-ranked states overall had at least four indicators in the bottom half of the distribution.

“All states need to do better on preventive care” she says.

Under PPACA, accountable care is being reinforced with provider bonus payment and innovation grants. Schoen says even low-ranking states like Texas have provider systems that want to improve and use measurement data to find opportunities for better care delivery. For example, and Blue Cross Blue Shield of Texas recently partnered with the Memorial Hermann Physician Network to form an accountable care organization for 100,000 members.

Dr. Blumenthal is particularly concerned about states that aren’t going to expand Medicaid eligibility in the near future. In areas with a gap between Medicaid and subsidized exchange coverage, there are fewer opportunities to narrow the healthcare quality and access disparities among higher and lower incomes.

“Medicaid is a lifesaver for low income Americans with poor health status,” he says.

The Commonwealth Fund recommendations include expanding insurance-including Medicaid-and creating policies to hold insurers accountable for fostering timely access to provider networks and quality care. It also recommends holding provider systems accountable for population health and advanced collaboration across the healthcare spectrum.