Guiding Action and Measuring Results: A Health System`s Use of America`s Health RankingsTM

Deborah Deatrick, MPH, Vice President, Community Health, MaineHealth and Andrew Coburn, Ph.D, Professor and Director, Population Health and Health Policy, Muskie School of Public Service, University of Southern Maine

Approaches to measuring and ranking health system performance are rapidly proliferating, both in the U.S. and around the globe. These efforts are being fueled by the trend toward greater accountability and transparency in health care as decision makers, including taxpayers, want to know if massive investments in medical care are yielding actual improvements in population health. Although performance measurement systems have captured the attention of many, there are relatively few examples of efforts to actually use health system performance reports and rankings to inform health care providers` decisions regarding priorities for community health improvement and corresponding resource allocations.

MaineHealth, a nonprofit, integrated health system serving 11 of Maine`s 16 counties and three-quarters of the state`s population, has used the America`s Health RankingsTM framework, indicators, and measures to develop the MaineHealth Health Index. Broader than just a performance measurement system, our Health Index is an initiative designed to guide the health system`s multi-million dollar investments in clinical care and community health and to track improvements in population health in the region served by the system. This Commentary describes the background and purposes of this initiative, the approach and methods for adapting the Rankings for use in this context, and the lessons learned to date.

MaineHealth is a vertically integrated health system formed in 1997 to improve healthcare quality and access while reducing the cost of care - a daunting task in one of the oldest and poorest states in the U.S. Anchored by Maine Medical Center, a 600-bed tertiary care teaching hospital in Portland, the system has grown to include eight hospitals, three long term care facilities, four home care agencies, a large network of primary care and specialty physicians, and a regional clinical laboratory spread over 11 of Maine`s 16 counties - a region that covers roughly 15,000 square miles and is predominantly rural but includes the most populated areas of the state.

Better alignment of our medical care and public health systems is essential for achieving significant improvements in the health of American people. In this period of renewed focus on health reform, the media and politicians are frequently quoting the now familiar refrain that the health of the U.S. lags all developed nations despite the largest annual per capita expenditures for health care in the world. Calls to action center on re-orienting our health care system to pay greater attention to prevention and population health.

But what does this mean `on the ground?` And more importantly, what should our priorities be for action to improve health? Health reform proposals have incorporated prevention and `wellness` health plan benefits expansions. More ambitious provisions, such as demonstrations of new Accountable Care Organizations and population-based financing options could open the door for a significant re-alignment of the health care financing system toward population-based health improvement. Despite these potential positive steps, long term gains in population health will require us to bridge the huge chasm between our enormous investments in medical care and our systems to improve health.

As is often the case in the U.S., state and local initiatives can lead the way in the absence of a national plan for health improvement. But where are we going? As Lurie and Fremont discuss, we currently lack adequate data, measures, and methods to identify the priority health problems to address, guide our actions, and account for our results. To this end, Wisconsin has recently used the framework of the America`s Health RankingsTM to launch a new county health rankings project that holds promise for stimulating local and state action for health improvement and for monitoring results.

Since 2002, MaineHealth`s investments in clinical quality improvement, community health, and other initiatives total approximately $30 million. The Board and senior management have increasingly sought ways to assess the value and impact of these investments. With respect to the system`s population and community health initiatives, America`s Health RankingsTM offered a scientifically validated and highly recognized framework for helping to guide investments and, over time, assess results.

The goal of MaineHealth`s Health Index initiative is to identify and implement clinical and community interventions that can significantly improve the health of the populations served by the MaineHealth system. The system has a well-established track record of committing its own resources to advance strategic clinical and community health initiatives. Examples include equipping affiliated primary care physicians with electronic medical records, embedding nurse care managers in primary care practices, and leadership of a multi-community project to reduce childhood obesity.

The Health Index initiative was born in late 2008 when, as the system`s Board of Trustees was poised to substantially increase the investment in these and other strategies, they challenged senior management to determine which interventions have been most successful in `moving the needle` to improve the health of the population. Senior management and the system`s Board proposed that the Health Index initiative should meet four core criteria: 1) be consistent with Board vision and direction; 2) have the potential to influence health outcomes; 3) provide an explicit framework for securing and allocating resources; and 4) provide better accountability for health system actions.

Aligning MaineHealth`s current and future initiatives and investments with the most pressing health improvement problems and opportunities is the core strategy for achieving this goal. The America`s Health RankingsTM indicators and measures have served as the starting point for this strategy. The 2008 America`s Health RankingsTM report ranked Maine 9th in the U.S., dipping from 7th place in 2007. While the state has consistently placed in the top 25% of states in the Rankings since 1990, our position on several indicators has changed dramatically over the years (e.g. childhood immunizations, where Maine fell from 8th in 2003 to 40th in 2007). These `challenges,` as they are termed in America`s Health RankingsTM, were a key element in engaging senior health system leaders, as well as clinical and public health stakeholders who expressed passionate opinions about how we could and should do better. Beyond helping to mobilize support within and outside MaineHealth for this initiative, the America`s Health RankingsTM framework provided a basic conceptual overlay for four planning and implementation steps we pursued over a 12 month period. These were:

(1)Creation of a system-wide MaineHealth Health Index Advisory Workgroup The MaineHealth Health Index initiative has been led by the system`s Vice President for Community Health and a small team of internal staff and consultants with considerable medical and public health expertise. Preliminary work focused on a review of similar ranking reports published by state, regional, and national organizations. The Health Index Advisory Workgroup, representing the diverse organizations and clinical specialties that comprise the system, was formed in late 2008 to provide input into the process, validate final products, and ultimately, facilitate the collaboration that will be vital to successful implementation of strategic initiatives targeted to our priorities for health improvement. A communications strategy was initiated early in the process to assure that internal and external committees and stakeholders were well-informed.In March of 2009, the America`s Health RankingsTM Scientific Advisory Committee Chair met on site with the Workgroup in a day-long meeting to assist with the discussion of priority indicators and measures.

(2)Select priority Determinants and Outcomes In reviewing the America`s Health RankingsTM indicators and measures with our Workgroup it became immediately apparent that some were more amenable to action by MaineHealth than others. We agreed, therefore, to focus on a set of 14 Determinants and Outcomes, understanding that MaineHealth may have a secondary role in addressing other indicators through its extensive partnerships with other state and community-level organizations.

To further prioritize the remaining Determinants and Outcomes, the staff developed a set of Logic Models that define specific intermediate and process outcome measures that, based on available evidence, are causally linked to long term outcomes. In a day-long meeting with the Workgroup, these Logic Models were reviewed to identify potential strategies for achieving high-level outcomes. The resulting framework, including the Logic Models and associated indicators and measures, was then sent back to the Workgroup to rank each of the items based on considerations of the potential for improving health, the likelihood of success, alignment with partners, and consistency with MaineHealth mission and interests. This ranking produced a set of six Tier 1-Highest Priority indicators that will be the primary initial focus of the MaineHealth Health Index initiative:

• Immunization Coverage (% of children 19-35 months)
• Prevalence of Smoking (% of total population)
• Prevalence of Obesity (% of total population)
• Cardiovascular Deaths (per 100,000 population)
• Cancer Deaths (per 100,000 population)
• Preventable Hospitalizations (per 1,000 Medicare enrollees)

(3)Assessment of current and future clinical, program, and other strategies needed to effectively address the targeted Determinants and Outcomes

A key next step will be to carefully inventory and assess existing clinical, community health and other initiatives and resources that may be related to these six priority areas. Evaluating these activities and resources against available evidence regarding what works and identifying new strategies that could enhance impact and outcomes will be key elements of this process.

(4)Obtain new resources to fund these priorities

The final and most important step was to advocate for the allocation of significant new resources to fund these priorities-a total of $1 million in FY 2010, with the potential for comparable annual increases in each of the next several years. In early September 2009 the MaineHealth Board considered the recommendations of the MaineHealth Health Index initiative and senior Management and approved our request for dedicated positions to lead the Index initiative, as they approved funding for new, specific Index-driven initiatives in tobacco, obesity, child immunizations, cancer, and preventable hospitalizations. We believe these actions provide clear evidence that the initiative has demonstrated its tremendous potential value to the health system. Now, our task is to document the return on their investments. Looking ahead, the inaugural MaineHealth Health Index Annual Report is slated for the spring of 2010, timed to coincide with the rollout of the system`s budget process.

The most important early lesson of this initiative has been the surprising depth of MaineHealth investments in clinical and community health improvement efforts that directly or indirectly affect population health. Although expanding the concept of health system accountability beyond quality, cost, and access to include improvement of population health is a new idea for many, our experience indicates that Board members, senior management, and key stakeholders are increasingly interested in a more comprehensive health system performance and accountability framework that includes population health measures.

The America`s Health RankingsTM framework has been a critical tool in helping to `make the case` for health system attention to population and community health. Although education on the background and science of the framework was certainly necessary among those unfamiliar with public health, America`s Health RankingsTM offered a scientifically validated and conceptually clear approach that proved compelling. Wide recognition and acceptance of America`s Health RankingsTM as the ‘gold standard` of actionable population health status reports was invaluable to jump-start this initiative.

While the America`s Health RankingsTM framework and the Logic Modeling approach we have used offer an invaluable, conceptual bridge between assessment, planning and action, deciding how best to address specific Determinants and/or Outcomes is challenging. Moreover, demonstrating over time that the MaineHealth investments in population health are `moving the needle` on the indicators and measures we are targeting will be challenging. Although there is research literature that offers evidence on many interventions, linking strategies and programs to outcomes requires faith that the art and science of the process will converge to produce improvements in population health.

In the end though, we return to the underlying importance of the goal of aligning our medical care and public health systems and resources to achieve significant improvements in the health of American people and communities. The MaineHealth Health Index initiative is the beginning and not the end of a process of re-alignment that will yield important lessons on the `on the ground` realities of bridging our medical care and public health systems.

Lurie, N and A. Fremont (2009) Journal of the American Medical Association 302:84-86.
Kindig, D. and G. Stoddard (2003) What is population health? American Journal of Public Health 93:380-383
Lurie, N and A. Fremont (2009) Building bridges between medical care and public health Journal of the American Medical Association 302:84-86.
Peppard, P. et al. (2008) Ranking community health status to stimulate discussion of local public health issues: The Wisconsin County Health Rankings American Journal of Public Health 98: 209-212