Minnesota's Health Care Performance Scorecard: Putting the state's ...

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Minnesota’s Health Care Performance Scorecard:

Putting the state’s health care system in national perspective

January, 2015

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ContentsPreface

Executive summary 1

Overviewoffindings 1

Recommendations 2

1.Introduction 3

ChallengesfacingMinnesota’shealthcaresystem 3

Health care reform 4

TheopportunitytobuildahealthierMinnesota 6

2.Minnesota’shealthcaresysteminnationalperspective 9

Performanceevaluationframework 9

Scorecardresultsandhighlights 11

3.Strengthsandopportunities 21

Areasofdistinctiveness 21

Opportunitiesforimprovement 23

4.Thepathforward 29

NextstepsinhealthcarereforminMinnesota 29

Recommendations 29

PerformanceScorecard 33

TechnicalAppendix 43

1.TimelineofhealthcarereforminMinnesota 43

2. Acronyms 44

3.Measuredefinitions 45

4.Calculationofstaterank 56

Citations 57

PREFACE

ThisisacriticaltimeintheevolutionofMinnesota’shealthcaresystem.Anationalleaderinhealthcaredeliveryaswellasoverallpopulationhealth,MinnesotaisundertakinganambitioussetofreformsandexperimentingwithinnovativepaymentanddeliverymodelsthatwillimpacteveryaspectofthehealthcaresystemandthelivesofMinnesotansineverycornerofthestate.

Thesereformsofferpromisebutalsointroduceuncertainty.Properlymanagedandexecuted,theycanhelpestablishasustainable,market-based,patient-centeredsystem,withimprovedqualityandlowercosts.Ifnotmanagedcorrectly,however,theymightcreateconditionsthatsuppressinnovationanddrivecostsevenhigher.

Inthisperiodofrapidchangeandexperimentation,itisessentialtohaveaclearviewofhowthesystemisperformingandtounderstandwhatmustbedonetomakethemostoftheopportunitybefore us.

Toachievethesegoals,theMinnesotaBusinessPartnership(MBP)hasdevelopedtheHealthCarePerformanceScorecarddescribedinthisreport.Thepurposeofthereportistoprovideacomprehensivebutaccessiblefactbaseonthesystem’sperformancetoinformconsumers,employers,decisionmakersandopinionleaders.Wehighlightkeychallengesandareasofopportunity,andofferafewpracticalrecommendationstoimprovethestate’shealthcaresystem.

ThisresearchhasbeensponsoredbytheMinnesotaBusinessPartnershipaspartoftheitshealthcarereformprogram.Weareenormouslygratefultoanumberofindividualsandorganizationsthathavesupportedandcontributedtothiswork.WeareparticularlyindebtedtoJimChaseofMinnesotaCommunityMeasurement,DonnaZimmermanofHealthPartners,andPaulMattessichoftheWilderFoundationfortheirguidanceandsupport.

MBP Health Policy Committee

Co-chairs: Policy Director:

Mary Brainerd Lucas NessePresident&CEOHealthPartners

Mike FitermanChairman&CEOLibertyDiversifiedInternational

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EXECUTIVE SUMMARY

Minnesota’shealthcaresystemisinaperiodoftransition.Longrecognizedasanationalleaderinhealthcare,Minnesotaishometoanumberofworld-classmedicalandresearchinstitutions,andconsistentlyranksamongthebest-performingstatesintermsofcoverage,accesstohigh-qualitycare,andoverallhealthofthepopulation.However,thestatealsofacesmanyofthesamechallengesstraininghealthcaresystemsnationwide.Theagingpopulation,increasingprevalenceofchronicconditions,andunsustainablegrowthinthecostofcareposechallengesthatwillrequiremeaningful,systemwidereforminthewayweprovideandpayforcare,aswellasthewaysinwhichwemanagethehealthofthepopulation.Anumberofambitiousprogramsarecurrentlybeingimplementedtoaddressthesechallengesaspartofstateandfederalhealthcarereformlaws,aswellasthroughprivateandsocialsectorinitiatives.ThesereformsareunprecedentedinMinnesota’shistoryintheirscope,scale,andcomplexity,andwillimpacteverypartofthestate’shealthcaresysteminthecomingyears.

Inthemidstofthisrapidchange,itiscriticallyimportanttounderstandhowthehealthcaresystemisperforming:Whereisthestatedoingwell,whereisitfallingbehind,howareweproceedingwithplannedreforms,andhowwellaretheyworking?ThisreportandtheMinnesotaHealthCarePerformanceScorecardonwhichitisbasedareintendedtoprovideafactualfoundationwithwhichtoaddressthesequestions.Thegoalofthisworkistoestablishacomprehensiveyetconciseassessmentofhowthestate’shealthcaresystemisperformingrelativetothoseofotherstatessothatwemightbetteridentifystrengthstobuildupon,aswellasgapsandopportunitiesforimprovement.Drawinguponthisresearch,thereportmakesanumberofpracticalrecommendationsforhowthestateandthebusinesscommunitycanworktogethertosupportandimprovethehealthcaresysteminthisperiodofdynamicchange.

Overview of findings

ThePerformanceScorecardevaluatesMinnesota’shealthcaresystemrelativetothoseofotherstatesandthenationasawholealongfivedimensionsofperformance:

1. Coverage and access,includinghealthcarecoverage,systemcapacity,andaccesstohealthcareservices

2. Population health,includinghealthcareriskfactors,prevalenceandincidenceofillnessandinjury,andhealthoutcomes

3.Health care delivery,includingpatientexperienceandqualityofcare

4. Health care cost,includingtotalcostofcare,utilization,andunitcosts

5. Status of health care reform efforts,includingstatehealthcareexchanges,Medicaidexpansion,systeminitiativestoadoptvalue-basedpaymentmodelsandincreasetransparency,andadoptionofhealthinformationtechnology(HIT)

Minnesota’shealthcaresystemfaresverywellwhencomparedwithotherstatesalongthesedimensions,andisrankedfirstinthenationoverall.

Thestate’sresultsareparticularlyimpressiveincoverageandaccess,healthoutcomes,andqualityofcare.Ithasamongthelowestrateofuninsuredinthecountry,andperformsverywellacrossmostavailablequalityandoutcomemeasures.Minnesotahasoneofthecountry’shealthiestpopulations,withfewerresidentsreporting“poor”or“fair”healththanthoseofanyotherstate.Minnesotaalsocomparesquitefavorablyinseveralaspectsofsystemreform–mostnotablytheadoptionofhealthinformationtechnology(HIT),reporting,andtransparency.

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Thestatecompareslesswellinhealthcarecost,whereitisranked22ndoverall.Thisrankingreflectstheaveragestaterankacrossanumberofmeasuresoftotalcostofcare,utilization,andunitcost.ThesemeasuresaredetailedinChapter2,andinthePerformanceScorecardattheendofthisreport.

Whiletotalcostofcarevariessignificantlybypayercategory,theavailablemeasuressuggestthatutilizationlevelsareclosetothenationalaverageandthatunitcostsarehigherthanaverage,evenwhencontrollingforcasemixandwageindex.Thesemeasuresmustbeconsideredtogetherwiththestate’shighlevelsofcoverage,access,andqualityofcaretocreateacomprehensiveviewofhealthcarevalue.Theymustalsobeconsideredalongsidegrowthinhealthcarespending–which,thoughslightlylowerthanthenationalaverageinrecentyears,hasoutpacedgrowthinthestate’sGDPbytwotimesoverthepastdecadeonacumulative,percapitabasis.WhileMinnesotahasoneofthebesthealthcaresystemsofanystatealongmostdimensionsofperformance,itmustcontendwiththesamechallengeofunsustainablespendinggrowthfacingthenationasawhole.

Overall,weidentifyfourstrengthsandfourareasofopportunity:

Areas of distinctiveness Opportunities for improvement

• Nation-leadinghealthcarecoverageandaccess to care • Reducegrowthinhealthcarespending

• Advancedmeasurementandreportinginfrastructure

• Addressgapsinthetreatmentofpopulationswithspecialneeds

• Highdegreeofcarecoordinationandsystemintegration

• Addressgapsinthemanagementofpopulation health

• Highqualityofcareandpopulationhealth • Mitigatedisparitiesinhealthcareaccessand outcomes

Recommendations

Basedonthisresearch,andinconsiderationofthesystemwidechangescurrentlyunderway,weproposesixrecommendationsforactionsthatthebusinesscommunityshouldtakeinpartnershipwiththestate.TheserecommendationsareintendedtohelprealizethepotentialofhealthcarereforminMinnesota,andtoensurethatthechangesunderwayaddressthestate’smostpressingneedsbypromotinggreaterefficiency,transparency,andconsumerchoice.

Thesixrecommendationsare:

1.Advocatetoextendexistingpublic–privatepartnershipsforhealthcaremeasurementtoaddressgaps,betterassessdisparities,andpromotegreateraccountabilityforprovidingaffordable,highqualitycare

2.Bringleadersinthestate’shealthcaredeliveryandmedicaltechnologysectorstogethertopartneroninnovationsdesignedtoimprovepopulationhealth,patientexperience,andaffordability

3.Drawonbestpracticestoinformconsumersabouttheirhealthandthehealthcaresystem,andtopromotegreaterconsumerengagement

4.Promotebestpracticesinemployeeandfamilywellnessprograms,includingcoordinationacrossemployers

5.Partnerwithstateagenciestohelpthemproduceanimplementationroadmapandperformanceaccountabilityframeworkforreforminitiativesanddemonstrations

6.SharefindingswidelyinthecommunitytoincreaseawarenessofMinnesota’sperformanceinhealthandhealthcare,andoftheeffortsunderwaytofurtherimprovehealthinthestate

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1. INTRODUCTION

Challenges facing Minnesota’s health care system

Minnesotaiswidelyrecognizedasoneofthecountry’shealthieststatesandasanationalleaderinhealthcare.ThestateconsistentlyranksatthetopofthelistinUnitedHealthFoundation’sAmerica’sHealthRankings,anannualreportassessingdeterminantsofhealthandhealthoutcomesatthestatelevel.1In2013,Minnesotawasrankedthethird-healthieststateinAmerica,overall,andthefirstintermsofhealthoutcomes.Thesefindingsareconsistentwiththoseofothernationalstudiesofoverallhealth system performance.2

Thestate’sreputationforexcellenceinhealthcareisdueinparttoitspioneeringhealthplans,providersystems,andresearchorganizations.Minnesotaishometoanumberofleadinghealthplanswithalonghistoryofinnovationinpaymentandcaremanagement.AfewnotableexamplesincludeHealthPartners,Medica,andBCBSMinnesota.

Thestatealsoclaimsseveralnationallyandinternationallyrecognizedproviderandresearchorganizations,includingtheMayoClinic,FairviewHealthServices,EssentiaHealth,AllinaHealth,andHealthPartners.Asevidenceoftheexcellentqualityofcareavailableinthestate,theMayoClinicwasrecentlyrecognizedasthebesthospitalinthenationfor2014–15byU.S. News & World Report.3

Together,theseorganizationshavemadeMinnesotaaleadingnationallaboratoryformedicalresearchandforinnovationinhealthcarepaymentanddeliverymodels.Thestatehaslongbeenrecognizedasaleaderinpatient-centered,community-basedcare,andinintegrateddeliverymodels.Itishome,forexample,tothreeofthenation’s19PioneerAccountableCareOrganizations,andsomeofthecountry’smostwidelyrespectedhealthcarehomeprograms.4

WhileMinnesotahasmuchtobeproudofwithrespecttoitshealthcaresystem,itfacesanumberofchallengesthathavedirectimplicationsnotjustforthewell-beingofitspopulation,butalsoforthestate’seconomy.Thesechallengesbroadlymirrorthosestrainingthehealthcaresystemnationwide.Asisthecasenationally,Minnesotaisexperiencingsignificantgrowthintheprevalenceofcostlychronicconditionsandindicatorsoffuturehealthproblems.Theobesityrate,forexample,hasincreasedmorethan10percentagepointsoverthepasttwodecades,from14.6%ofthepopulationin1995tomorethan25%in2010.5ThepercentageofadultsinMinnesotadiagnosedwithdiabeteshasnearlydoubledinthissametimeperiod.6Thoughstillbelowthenationalaverage,thesetrendshighlightagrowingproblemthatwillbecomeincreasinglydifficultandcostlytomanageifnotaddressed.

Changingdemographicsposeanotherchallenge.TheagingofthepopulationinMinnesota(andnationally)isincreasingthediseaseburdenandshiftingcoststogovernment-runhealthcareprograms.Thisshiftwillexacerbateregionaldisparitiesinhealth,astheproportionofthepopulationover65isgrowingmorequicklyinthestate’sruralcounties.Minnesotaisalsofacingadistinctsetofchallengesassociatedwiththechangingcompositionofitspopulation.Thestate’snon-whitepopulationhasgrownfrom6%in1990tomorethan15%in2010.Thisgrowthhasbeendrivenpredominatelybyimmigration,withthemostrapidgrowthfromAfrica.7 In future years, the state expectsmostpopulationgainstobeincommunitiesofcolor.Thisgrowthintheimmigrantpopulationandthestate’sincreasingethnicandculturaldiversityhavemanybenefits,butalsoposenewchallengesforlocalhealthcaresystems,whichmustaddressdifferentunderlyinghealthneedsandbridgeincreasinglyvariedculturalandlinguisticbarriers.

Finally,thestateisgrapplingwiththesameunsustainablegrowthinhealthcarespendingthatthreatensthehealthcaresystemnationwide.Whilethegrowthintotalhealthcarespendingslowedconsiderablysince2008—duelargelytothegreatrecession—thelong-termtrendisnotpromising.Since2005,healthcarespendinghasincreased35%whilethestateeconomyhasgrownby22%.8

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Health care reform

Policymakersandprivatesectorleadershaveundertakenanambitioussetofreformsinresponsetothesechallenges.PriortonationalhealthcarereformwiththepassageoftheAffordableCareAct(ACA)in2010,Minnesotapasseditsown,statewideHealthCareReformActin2008.Thislegislationbuiltuponabroadsetofpublicandprivatesectorinitiativesandexperimentalmodelsalreadyunderwayinthestatetoimproveaccesstocareandpopulationhealth,increasetransparencyintoprovidercostandperformance,acceleratepaymentreform,andpromotegreaterconsumerengagement.Thekeyinitiativesestablishedbythislawinclude:

• Health care homes.The2008ReformActmandatedthecreationofastandardized,statewidemedicalhomemodeltopromotepatient-centeredprimarycare.Thismodelincludedtheestablishmentofacommonsetofstandardsformedicalhomecertification,acertificationprocess,andapaymentmethodologytocompensateforcarecoordination.

• Provider Peer Grouping (PPG).Aspartofabroaderefforttopromotegreatertransparencyintoprovidercostandquality,thereformlawcalledforthecreationoftheProviderPeerGrouping(PPG)process.Inordertodothis,theDepartmentofHealthcreatedtheMinnesotaHealthCareClaimsReportingSystem(MHCCRS).Thissystemcollectsandaggregatesallpayerencounterdata.TheAllPayerClaimsDatabase(APCD)wasinitiallydesignedtosupporthealthcareproviderperformanceassessmentaspartoftheProviderPeerGroupinginitiative,butisunderevaluationtosupportabroadersetofapplications.9

• Statewide Health Improvement Program (SHIP). TTheReformActestablishedtheSHIPtohelplocalcommunitiesemployevidence-basedpopulationhealthstrategiesinschools,worksites,andhealthcaresettingstoaddresslifestylerelatedhealthissuessuchasobesityandalcoholandtobacco consumption.

• Statewide Quality Reporting and Measurement System (SQRMS).TheReformActmandatedtheestablishmentofastandardizedsetofqualitymeasurestobeusedbyprovidersstatewide.SQRMSwasdesignedtoadoptmeasurescreatedthroughMinnesotaCommunityMeasurement(MNCM)andtoestablishaframeworkfortheongoingdevelopmentandreportingofmeasuresthroughMNCM.

Inadditiontothesenewprograms,theHealthCareReformActalsoincludedanumberofprovisionsdesignedtoincreaseaccesstoaffordablehealthcarecoverage,promotetheuseofhealthinformationtechnology(HIT),andadvancepaymentreform.

The2008HealthCareReformActbuiltuponmorethan15yearsofprecedinglegislationandinnovationsinhealthcarereporting,payment,anddeliverymodelsdrivencollaborativelybythepublicandprivatesectors.ThispartnershipbetweenprivateandpublicsectorleadershiptoadvancestatewidehealthcarereformisoneofthedistinctivefeaturesofMinnesota’shealthcaresystem.Atimelineoutliningthecriticalreformsofthepast20yearscanbefoundintheAppendix,andasummaryofsomeofthecriticalinitiativesisprovidedinExhibit1.

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Exhibit 1. Summary of key initiatives preceding the Reform Act of 2008

• Coverage.Minnesotahasoneofthelowestratesofuninsuredinthecountry.Thisistheresultofbothhigherthanaverageprivatesectorcoverageandprogramsdesignedtoensureaccessforhigh-riskandlow-incomeMinnesotans.TheMinnesotaComprehensiveHealthAssociation(MCHA)wascreatedin1976asthehigh-riskhealthinsurancepoolsellingindividualproductstoindividualswhoweredeniedcoverageelsewherebecauseofpre-existingconditions.The MinnesotaCareprogram,agovernment-subsidizedhealthplan,wascreatedin1992tocoverstateresidentswithlowtomoderateincomeswhoareunabletoaffordinsuranceontheirownbutdonototherwisequalifyforcoverageunderthestate’straditionalMedicaidprogram(Medical Assistance).MNCareeffectivelyexpandedMedicaideligibilitylevelsforlow-incomeadultsfifteenyearsbeforethenationalefforttoexpandcoverageundertheACA.

• Value-based payment.Employersgavethestateaheadstartinre-inventinghealthcarepurchasingandreimbursement.Businesscoalitions,suchasMinnesota’sHealthActionGroup(formerlytheMinnesota’sBuyer’sHealthActionGroup)havebeenexperimentingwithprogramsthatlinkproviderreimbursementtooutcomeswellbeforethemorerecentnationalroll-outofAccountableCareOrganizations(ACOs)andrelatedmodels.TwonotableinnovationsincludeBridgestoExcellence,apurchaser-ledpay-for-performanceprogramthatrewardsclinicsbasedonperformanceonqualityindicators,andeValue8,anonlinetoolthatprovides member organizationswithcomparativecostandqualityinformationonhealthplans.Other non-profitorganizations,suchastheInstituteforClinicalSystemsImprovement(ICSI),convenestakeholderstopromotebestpracticecaredeliveryandtoacceleratesystemtransformation.Forexample,inthespringof2011,ICSIbroughttogethertheMinnesotaHospitalAssociation,StratisHealth,hospitals,andcommunitypartnerstoimplementitshighlyeffectiveReducingAvoidableReadmissionsEffectively(RARE)Campaign,astatewideefforttoreduceavoidablehospitaladmissions.

• Measurement and transparency. These innovations in payment structure were supported by activityinmeasurementandpublicreportingthatallowforeffectiveimplementationofvalue-basedpaymentarrangements.MinnesotaCommunityMeasurement,a commercialhealthplan-initiatedgroupcommittedtopublicreportingofthehealthcaresector’sperformance,producedareportonproviderperformanceonselectqualitymetricsforeveryclinicinthestate,afeatthatwasthefirstofitskindinthenationin2004.PatientChoiceHealthcareInc.wasformedin2000asaprogramthatsortedprovidersintotiersbasedoncostandqualityonbehalfofself-insuredemployers,oneofmanytoolsdevelopedtomakehealthplanandproviderperformancemoretransparentforpurchasersandconsumers.

Inadditiontotheseinitiatives,MinnesotaisalsonowengagedinaseparatesetofreformsthatfollowedthepassageoftheAffordableCareAct.DespitetheongoingnationalpoliticalstruggleoverimplementationoftheACA,Minnesotahaslargelyembracedthelaw,includingthoseelementslefttothediscretionofthestates.IthasoptedtocreateitsownstateexchangeandtofurtherexpandMedicaidcoverage,andisactivelyparticipatinginnationalpilotsincaredeliveryandpaymentinnovation.MinnesotawasthefirststatetoexpandMedicaidin2010byextendingcoverageunderitstraditionalMedicalAssistanceprogramtoadultswithincomesupto75%oftheFederalPovertyLevel(FPL). 10InMarch2013,GovernorDaytonsignedMNsure,thestate-basedexchange,intolaw,makingMinnesotaoneof17statestoestablishitsownstate-basedmarketplace.11

ThestatehasalsobeenanactiveparticipantinseveralprogramsrunthroughtheCentersforMedicareandMedicaidInnovation(CMMI)todesignandtestinnovativepaymentanddeliverymodels.12

Together,thesevariedpublicandprivatesectorinitiativeshavecreatedaperiodofdynamicchangeinMinnesotathatwillultimatelyimpacteverycomponentofthehealthcaresystem,includingregulators,payers,providers,andmanufacturers,aswellasconsumersandemployers.

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The opportunity to build a healthier Minnesota

Withsomuchatstakeitisessentialthatthestate’shealthcaresystemstakeholdersworktogetherto make the most of the opportunity before us. The business community has a vital role to play in thiseffort.Minnesota’sbusinessesbenefitfromthestate’shealthcaresystemandprosperwiththegoodhealthofthepopulation.Theyalsohavearesponsibilitytopromotethegoodhealthofthecommunitiesinwhichtheiremployeesandcustomersliveandwork.

Throughitsactiveinvolvementandleadershiponhealthcareissues,theprivatesectorhascreatedastrongfoundationforcollaborationwiththestateandauniqueplatformfromwhichtoeffectchange.Twentyyearsofeffectivepartnershiphavecreatednetworksandnonprofitorganizations(suchastheInstituteforClinicalSystemsIntegration,StratisHealth,andMinnesotaCommunityMeasurement)whichunitethestate’semployers,providers,andstateagenciesinthesharedgoalofimprovinghealthin the state.

Theprivatesector’sroleinshapingthestate’shealthcaresystemisfurtherstrengthenedbytheremarkableconcentrationofworld-classhealthcareorganizationsbasedinMinnesota.Inadditiontothehealthplansandproviderorganizationspreviouslynoted,thestateisalsohometoleadingnationalpayers,manufacturers,andmedicaltechnologycompanies.TwonotableexamplesincludeUnitedHealthcare–thenation’slargestprivatepayer–andMedtronic,aworldleaderinmedicaldevicetechnology.

Thehealthcaresector,vitaltothestate’seconomy,accountsforalargeandgrowingportionoftheemploymentbase;16ofthestate’stop50employersarehealthcarecompanies,whichrepresent32%ofMinnesota’sjobs.13Theseincludehealthcareproviders,aswellashealthinsurancecompanies,manufacturers,andmedicaltechnologycompanies.Healthcareprovidersaloneemployedmorethan16%oftheworkforcein2010andareoneoftheeconomy’sfastest-growingsegments.Employmentinthehealthcareandsocialassistancesectorgrew3.4%between2008and2010,whileallotherindustriesexperienceda6.1%declineduringthesameperiod.14

Exhibit 2. Minnesota’s health care sector employment statistics

-6.1

3.4

16.0

Percentage of the workforce employed in health services, statewide (2010)

Growth in employment in health care vs. other industries (2008-2010)

Health care services

All other

Source: Minnesota Department of Employment and Economic Development analysis of Labor Market Information Office data, February 2011.

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Theseorganizations,criticaltothehealthofthestate’seconomyandtothesocialfabricofthecitiesandcommunitiesinwhichtheyoperate,alsoofferaconcentrationofhealthcaretechnicalexpertiseandmanagerialexperiencethatcanbeusedtodevelopinnovative,practical,andmarket-orientedhealthcareinitiatives.

TheMinnesotaBusinessPartnershipisworkingtocoordinatetheleadersoftheseorganizationsandotherlargeemployersinthestate.Asabusinesscoalition,MBPconvenestheseniorleadersofmorethan100ofthestate’slargestemployersandcoordinatescollectiveactiontostrengthenthestate’seconomyandcommunities,andtopromotehealthinthestate.Atthiscriticaljunctureintheevolutionofthestate’shealthcaresystem,MBPanditsmembershipareworkingtopromotemarket-basedreformsthatachieveoptimalhealthoutcomes,reducecosts,andincreaseaccesstoaffordablecare.

Thisreport—andtheMinnesotaHealthCarePerformanceScorecardonwhichitisbased—areintendedtosupportthismissionbyprovidingacomprehensive,objective,andbalancedassessmentofthestate’shealthcaresystem.Inthemidstofrapid,disruptivechange,itisessentialthatthedecisionmakersandkeystakeholdersinthestatehaveaclearandsharedunderstandingofhowthesystemisperforming.Wemustknowwherethestateismeetingitsgoalsandwhereitisn’t,andhowaccesstocareaswellasthecostandqualityofcarearechanging.Thereportcomparestheperformanceofthestate’shealthcaresystemwiththoseofotherstatesandthenationalaverage,sothatwemightbetteridentifystrengthstobuildonaswellasgapsandopportunitiesforimprovement.Drawinguponthisresearch,thereportmakesanumberofpracticalrecommendationsforhowthestateandthebusinesscommunitycanworktogethertosupportandimprovethehealthcaresystem.

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2. MINNESOTA’S HEALTH CARE SYSTEM IN NATIONAL PERSPECTIVE

Performance evaluation framework

TheMinnesotaHealthCarePerformanceScorecardisorganizedaroundfivemajordimensionsofperformance,asoutlinedinExhibit3.Thesedimensionsarefurtherbrokendowninto14sub-categories,ordomains.Thefive-partframeworkisgroundedinthe“TripleAim,”developedbytheInstituteforHealthcareImprovement(IHI).Widelyusedbyhealthcareorganizationsaroundtheworld,theTripleAimassesseshealthcaresystemperformanceasafunctionofthreeobjectives:(i)toimprovethepatientexperience(includingqualityandsatisfactionofcare);(ii)toimprovethehealthofthepopulation;and(iii)toreducepercapitacostofcare.

Wehavebuiltuponthesethreecoredimensions(reflectedincategoriestwothroughfouronthescorecard)andexpandedthemtoincludetwoadditionaldimensionsofhealthsystemperformance:healthcarecoverageandaccess,andthestatusofhealthcarereformimplementation.

Exhibit 3. Performance evaluation framework

1 Coverage and access1.1 Healthcarecoverage

3.1 Patient experience

2.1 Health care risk factors

4.1 Total cost of care

5.1 HITadoption

1.2 Systemcapacityandaccess

3.2 Quality of care

2.2 Prevalenceandincidence

4.2 Utilization

5.2 System initiatives

2.3 Health outcomes

4.3 Unit cost

5.3 Medicaidexpansion

5.4 Statehealthexchanges

2 Population health

3 Health care delivery

4 Health care cost

5 Status of health care reform efforts

Categories Adapted from the Triple Aim

Category Domain

Source:McKinseyHealthCareValueAnalytics

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Theperformancescorecardisorganizedaroundanaggregateview,summarizingthestate’sperformanceinallfivecategories,andmoredetailed,category-levelviewswithsupportinginformation.Intotal,thescorecardincludes154performancemetricscollectedfrommorethan40differentsources.Thesemetricsweredrawn,whereverpossible,frompublicsourcessothatthescorecardcanbeexternallyvalidatedandreplicated.

Thescorecardincludesbothnormativemetrics,usedtorankthestate’sperformance,anddescriptivemeasures,whicharenotusedforrankingbutconveyimportantinformation.15 The charts on the followingpagesreportthestate’sperformanceonthenormativemetrics.Thecompletescorecard,includingdescriptivemeasures,isincludedintheappendix.Theappendixalsoprovidesadditionaldetailonthecalculationofthestateranksandotheraspectsofthescorecardmethodology.

Thescorecardincludessixyearsofdata,covering2009to2014.Datawasnotavailableforallofthemetricsforalloftheyearsinthistimeperiod.Thescorecardalwaysreportsthemostrecentdata,andtheyearofthemostcurrentdataisreportedforeachmetricinthedetailed,category-specificviews.

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Scorecard results and highlights

Exhibit 4. Minnesota Health System Performance Scorecard summary

State Rank:

State rank represents a forced ranking of 1-51 for each state and the District of Columbia Ranking is based on normative metrics, with a rank of 1 indicating best performance The ranks are color coded as follow:

Distribution of metrics:

The distribution of normative metrics are shown across performance quintiles Performance is scored so that it is preferable to be in the top quiintile (1) for any metric The concentration of performance metrics by quintile within a given domain is represented by the size of the circles, with larger circles indicating a greater concentration of metrics

Legend

76-100% of metrics 51-75% 26 -50% 1-25% 0%

1-10State Ranking: 11-20 21-30 31-40 41-51

1(Top)

2 3 4 5(Bottom)

Category

4

5

State Total

Coverage and access

Population health

Healthcare delivery

Health care cost

Status of health care reform efforts

1

2

3

Catetory weighted state average

1.1

2.1

1.2

2.2

2.3

3.1

3.2

4.1

4.2

4.3

5.1

5.2

5.3

5.4

Health care coverage

System capacity and access

Prevalence and incidence

Health care risk factors

Health outcomes

Patient experience

Total cost of care

HIT adoption

System initiatives

State health care exchanges

Medicaid expansion

Unit cost

Utilization

Quality of care

Health system performance framework Distribution of metrics by performance quintile (1-5)

2

4

State rank (1-51)

Domain

Source: McKinsey Health Care Value Analytics and third party data sources

1

1

24

4222

425

1 82

6

11

13

5

1

12

7

12

3

2

Totalmetrics

Numbers in the circle represent individual performance metrics

2

48% 19% 10% 6%17%

2

2

4

4 2

9 2

1

4

#

1 1

3

32 1

1

32 1

31 1 1

1

31 3 2

1

4 1 3

1

1

11

4

333

2

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Overall,Minnesota’shealthcaresystemfaresverywellincomparisonwiththoseofotherstates.Itisrankedfirstinthenation,overall,acrossallfivecategoriesofperformance,andfaresparticularlywellincoverageandaccess,healthoutcomes,andqualityofcare.Nearlyhalfofallofthenormativemetricswereinthetopquintileinthemostrecentperformanceperiod,andnearlythree-quarterswereinthetoptwoquintiles.Thisresultisshowninthescorecardbothintheaggregatestatisticsreportedatthestatelevelandinthedistributionofmetricsacrossquintilesatthedomainlevel.Thebubblesinthescorecardshowthequintilesinwhichmetricsareconcentrated,withlargerbubblesindicatingagreaterpercentageofthemetricsinagivendomain.Thenumbersinthebubblesreflecttheactualcountofnormativemetricsinthespecifieddomainandperformancequintile.

Exhibit 5: Coverage and access

State Rank

11-2021-3031-40 1-1041-51Health care coverage1.1

1.2

*See Appendix for complete scorecard including descriptive statistics SOURCE: McKinsey Health Care Value Analytics and third party data sources

State Rank:

MN Value

National Average Year


1

Percent of PCP needs met (Current # of physicians/# of physicians required to eliminate HPSA status)

18% 23% 2012 26

Average doctor wait times (in minutes) 19 21 2011

Percent with inadequate healthcare coverage 9% 12% 2012 3

Percent of population in primary care health professional shortage areas (HPSAs)

18% 16% 2010 9

Payer Mix: Percent uninsured 9% 15% 2013 6

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Coverage and access*1

Minnesotarankedfirstinthecountry,overall,incoverageandaccess.In2013,just9%ofthestate’sresidentswereuninsured,comparedwith15%nationally.16 This was the sixth-lowest rate in the country,andhassincefallenevenlowerwiththelaunchofstatehealthinsuranceexchangesandtheexpansionofMedicaid.Minnesotaranksthird-lowestinthecountryinthepercentageofthepopulationwithinadequatecoverage.17 Minnesotaisalsodistinguishedbythehighproportionofthepopulationcoveredbycommercialinsurance.In2013,62%ofthestate’spopulationwasprivatelyinsured,comparedwith51%nationally.Thishighrateofcommercialcoveragereflectsthestate’slowunemploymentrate(4.5%comparedwith6.2%nationally)aswellahighrateofsmallbusinessesprovidingcoveragetotheiremployees.18 TheproportionofthepopulationcoveredbyMedicaidandMedicareiscorrespondinglylowerthanthenationalaverage,with16%ofthepopulationcoveredbyeachprogram.19

Whilethepercentageofthestate’sresidentsreceivingcarethroughsafetynetprogramsislowerthanthenationalaverage,theseprogramsareamongthemostgenerousinthecountryintermsofbotheligibilityandbenefits.ThankstotheMinnesotaCareprogramcreatedin1992,Minnesotawasoneofthefewstatesinthecountrythatprovidedsubsidizedcoveragetolow-incomeadultsnototherwiseeligibleforMedicaidbeforetheACA.ThebenefitsthestateMedicaidProgramoffersarealsounusuallygenerous,increasingbeneficiaries’meaningfulaccesstocare.20

MeasuresofsystemcapacityindicatethatMinnesotansexperiencebetter-than-averageaccesstoacutecarehospitals,specialistphysicians,andtraumacenters,asmeasuredbytheratioofstatepopulationtoproviders.However,with1,385individualsperprimarycarephysician(PCP)inthestate—comparedwithanationalaverageof1,265perPCP—residentsinsomepartsofthestatemayhave less access to primary care than those in other states.21

InsufficientaccesstoprimarycareismoresignificantinsomepartsofMinnesotathanothers,butthedisparityislesspronouncedthaninmanyotherstates.AccordingtotheU.S.DepartmentofHealthandHumanServices,just7%ofthestate’spopulationlivesindesignatedPrimaryCareHealthProfessionalShortageAreas(HPSAs),wheretherearemorethan3,500individualsperprimarycarephysician.Thisrateissignificantlybelowthenationalaverageof20%butpointstoapotentiallymeaningfulgapinaccessforsegmentsofthestate’spopulation.22

13

Exhibit 6: Population health

State Rank

11-2021-3031-40 1-1041-51Health care risk factors2.1

Prevalence and incidence2.2

Health outcomes2.3

MN Value


Occupational fatalities (per 100,000 workers) 2.6 3.3 2012

29Percent of high school students reporting cigarette use in the last month

18% 18% 2011

14Percent of adults designated as obese (BMI ≥ 30) 26% 28% 2012

1Percent of adults with high blood pressure 22% 29% 2009

Air Quality Index 0.81 0.68 2013 20

Injury deaths (per 100,000) 55 59 2010 11

Percent of adults reporting excessive drinking 18% 16% 2010 39Percent of persons 12 and over with any illicit drug use in the past month

8% 9% 2011 24

Percent of adults reporting no exercise in the last 30 days

18% 23% 2012 6

Percent of adults reporting consumption of fewer than 5 servings of fruits / vegetables per day

78% 76% 2009 35

Percent of the adults who self-report cigarette smoking 19% 21% 2011 11

Percent of children ages 10-17 that are designated as obese (BMI >95th percentile)

14% 16% 2011 19

Percent of Medicare beneficiaries with 2 or more chronic conditions

57% 69% 2012 7

Invasive cancer incidence rate (per 100,000) 476 459 2009 33

Percent of adults who have ever been told that they have diabetes

7% 9% 2010 4

Percent of adults who have ever been told that they have asthma

11% 14% 2010 4

Chlamydia case rate (per 100,000) 337.8 456.7 2012 8

Percent of adults with mental illness 17.4% 17.8% 2011 14

Gonorrhea case rate (per 100,000) 57.7 107.5 2012 15

Percent of adults that self-reported "poor" or "fair" health

12% 17% 2012 1

Gallup-Healthways Well-Being Index 69.7 66.2 2013 3

Stroke deaths (per 100,000) 36.1 39.1 2010 14

Alzheimer's disease deaths (per 100,000) 22.2 24.2 2010

Heart disease deaths (per 100,000) 122.1 182.8 2010 1

Influenza and pneumonia deaths (per 100,000) 10.3 16.5 2010 3

Infant mortality rate (per 1,000 live births) 4.5 6.1 2010 5

Homicide deaths (per 100,000) 1.8 5.5 2010 4

Suicide deaths (per 100,000) 10.8 11.8 2010

Percent of live births that are low birth weight 6.6% 8.1% 2011 5

Perinatal deaths (per 1,000 live births) 4.6 6.1 2010 6Hospital rates of early scheduled delivery: Percent of mothers who indicated elective delivery as a percent of total mothers who delivered between 37-39 weeks of gestation

27% 17% 2010 19


State Rank: 1Population health*2

18

11

14

14

Minnesotaalsoperformswellcomparedwithotherstatesinmeasuresofpopulationhealth.Thestateisrankedfirstinthecountry,overall,acrossmeasuresofhealthcareriskfactors,prevalenceandincidence,andhealthoutcomes.Thisisconsistentwiththestate’sstrongperformanceinAmerica’sHealthRankings,inwhichitrankedthird,overall,inmeasuresofpredictorsofhealthandhealthoutcomes.

Thestateconsistentlyscoreswellinkeymeasuresofhealthoutcomesanddiseaseprevalence.Minnesotahadthelowestpercentofitspopulation,at12%,reporting“poor”or“fair”healthin2012,23 comparedwiththenationalaverageof17%,andrankedthirdonthewell-beingindex.24 The state hasthefourth-lowestpercentageofadultswhohavebeentoldtheyhavediabetesorasthma.25 The statemortalityrateforheartdiseaseisthelowestinthecountry,andmeasuresofinfantmortalityandperinataldeathsaresimilarlylow,rankingfifthandsixthoutofallstatesrespectively.26

Healthcareriskfactorstellaslightlymorevariedstory.Minnesotanshavelowratesofhighbloodpressureandlowerratesofobesitythanthenationalaverage.However,thestatefaresworseinmeasuresofsomeunhealthylifestylebehaviors,suchasexcessivedrinkingandpoordiet,whereitranks39thand35th,respectively.ItshouldbenotedthatwhileMinnesotaappearsworsethanthenationalaverageonthesemeasures,thegapisfairlymodest.Forexample,Minnesotaranks39thinthepercentofadultswhoreportexcessivedrinking,buttheactualnumber(18%)isonly2%abovethenationalaverage.27

15

Exhibit 7: Health care delivery

State Rank

11-2021-3031-40 1-1041-51Patient experience3.1

3.2

MN Value


Quality of care

Average of Medicare ACOs' performance on 5 reported quality of care measures

1.24 1.00 2012 1

21Hospital safety score: Percent of hospitals that received a grade of "A"

29% 35% 2013

Medicare Part C Star Rating 4.5 3.6 2013 2

Percentage of adults reporting improved functioning from the public mental health system in the past 6 months

80% 70% 20115

Hospital: Percent of patients who reported "YES," they would definitely recommend the hospital (State average across hospitals)

72% 71% 201317

Average number of minutes patients spent in the ED before they were admitted

199 275 2013 3

State Rank: 4Health care delivery*3


Measuresofpatientexperienceandqualityofcarearemoredifficulttoassessaspartofanationalscorecardbecauselevelsandstandardsofreportingarehighlyinconsistentbetweenstates.State-leveldataarenotavailableformanyofthemetricsincludedinthiscategory,makingitimpossibletorankMinnesotaforthese.Inconsistencyinreportingalsocomplicatesinterpretationofthemetricsforwhichnationaldataareavailable.Forexample,Minnesotaranksveryclosetothenationalaverageinmostmeasuresofpatientexperience.However,itisdifficulttoknowwhetherthisisanaccuratereflectionofpatientexperience,asMinnesota’scommitmenttotransparencydeliversamuchhigherlevelofreporting.

Indicatorsofqualityofcarepaintamixedpicture.ThereareseveralareaswhereMinnesotaappearstofareverywell.Onaverage,theMinnesota-basedACOsparticipatingintheMedicareSharedSavingsandPioneerACOprogramsreportedhigherscoresonselectqualitymetricsthanthoseofanyotherstate.28 ThestaterankedsecondinthecountryinitsMedicarePartCStarrating,andfifthinthepercentofadultsreportingimprovedfunctioningfollowingtreatmentinthepublicmentalhealthsystem.29

16

Minnesotaranksnearorbelowthenationalaverageinafewimportantmeasures,despitestrongperformanceasaresultofthemeasuresbeing“toppedout.”Thislowerrankingoccurswhenallormoststatesperformveryclosetothebestpossiblelevel,creatingaclusterofresultsthatrendersrankslessmeaningful.Forexample,98%ofpatientsundergoingsurgeryonanoutpatientbasisinMinnesotareceivedantibioticsattherighttimecomparedwith99%nationally,butthisdiscrepancycausedthestatetoberanked34thinthecountryonthismetric.30Whilethestaterankisnotincorrect,itismisleadingformetricsliketheseforwhichthescoresaresotightlydistributed.

Twomeasuresstandout,however,thatpointtopotentiallymoremeaningfulgaps.Inanaggregatemeasureofhospitalsafety,theLeapfrogGroup,anindependentnationalnonprofitpatientsafetyorganization,awardedonly29%ofhospitalsinMinnesotaahospitalsafetyscoreof“A,”comparedwith35%ofhospitalsnationwide.31Thepercentoftwo-yearoldswhohadreceivedrecommendedimmunizationsalsostandsout.Minnesotaranked39thinthecountryonthismeasurein2012,with66%ofchildrenmeetingthestandard,comparedwith68.4%,nationally.32

17

Exhibit 8. Health care cost

State Rank

11-2021-3031-40 1-1041-51Total cost of care4.1

Utilization4.2

Unit cost4.3

22

Per capita personal health care expenditures by state of residence 36

Per capita hospital expense 38Total family premiums per enrolled employee at pri-vate-sector establishments (Average in dollars) 27

Total premiums for private-sector employees enrolled in single coverage (Average in dollars) 24

Total medical costs per member per month for commercial health plans (State average in dollars) 22

Total Medicare reimbursements per enrollee 5Part D spending per Medicare beneficiary 1CMS Medicare hospital spending per patient (Indexed to Medicare spending per patient on hospital care nationally)

5

Medicare spending per decedent during the last two years of life 17

Medicaid per enrollee payments: Total populationDual eligible enrollees: Duals' share of Medicaid spending 5

Medicaid expenditure as a percent of total state expenditures 17

Change in Medicaid expenditure as a percent of change in state GDP 40

Hospital admissions per 1,000 residents 25Hospital Emergency Room visits per 1,000 residents 11Average length of stay 37Commercial: Acute Hospital admissions per 1,000 members 30

All-cause 30-day Medicare readmission rate 21Percent of outpatients with low back pain who had MRI without trying other treatments 51

Percent of outpatients with brain CT scans who got a sinus CT scan at the same time 25

Percent of outpatient CT scans of the chest that were combination• (double) scans 20

Discharges for Ambulatory Care-Sensitive Conditions per 1,000 Medicare Enrollees 8

Percent of Medicare decedents seeing 10 or more different physicians during the last six months of life 20

Medicare Generic Dispensing Rate (GDR) 1

Commercial reimbursement per CPT: Index of payment for 100 most common physician office-based procedures

46

Commercial reimbursement per DRG: Index of payment for 100 most common DRG discharges 33

Cost per Acute Inpatient Admission 22Medicare Inpatient Prospective Payment System (IPPS)Geographic Adjustment Factor (GAF) (Average of Urban area-level weighted by Medicare discharges)

42

Weighted average Medicare reimbursement per DRG 36Cost per inpatient discharge adjusted for wage index and case mix 36

Total family premiums per enrolled employee at pri-vate-sector establishments (Average in dollars) as a percent of median household income

MN Value

$7,409

$2,801$15,408

$5,338

$284

$7,646$1,9270.90

$58,963

$6,23043%

28%

-71%

108.4352.96.057.9

17.6%50.9

2.6

2.4

50.6

34

81

1.39

1.05

$14,6111.06

1.03$15,445

24.9%

National Average

$6,815

$2,411$15,473

$5,384

$291

$9,584$2,6700.98

$69,947

$4,19236%

24%

233%

109.7424.45.456.2

19.1%36.5

2.8

3.7

66.6

42

74

1.00

1.00

$15,7351.00

1.00$13,731

30.3%

Year

2009

20122012

2012

2013

201020102013

2010

20112010

2012

2013

2012201220122012

20112013

2013

2013

2010

2010

2010

2012

2012

20122012

20122011

20124

State Rank:Health care cost*4


44

18

Minnesotaperformsleastwellonacomparativebasisinmeasuresofhealthcarecosts,ranking22ndacrosstheavailablemeasures.Aspreviouslynoted,thisrankingshouldnotbetakenatfacevalue,asmostofthecostmeasuresarenotadjustedfordifferencesincasemixorwageindex.

Themeasuresofhealthcarecostaredividedintothreedomains:totalcostofcare,utilization,andunit costs.

Withrespecttototalcostofcare,themetricstellaverydifferentstoryacrosspaymentcategories.Overall,Minnesotaspendsmorepercapitathanthenationalaverage,ranking36thina2009studyconductedbyCMS.MorerecentresearchsuggeststhatthetotalcostofcareinMinnesotahasgrownmoreslowlyinrecentyearsthanithasnationally(despiteamarkedreductioninthenationaltrend).However,spendinggrowthacceleratedin2012aftertwoyearsofveryslowgrowth.33 Relative levelsofpercapitaspendinglookverydifferentwhenbrokendownbysegment.Medicarespendingperbeneficiaryisamongthelowestinthecountry(ranking5th,overall),whileMedicaidspendingperenrolleeisamongthehighest,ranking43rd.34Percapitaspendingamongthecommerciallyinsuredismoredifficulttomeasurebut—judgingbyaveragepremiums—appearsclosertothenationalaverage.35

Measuresofutilizationtellasimilarlymixedstory.Therearebrightspots:thestatehasthecountry’shighestgenericdispensingrate(GDR)forMedicarebeneficiaries,forexample,andhasarelativelylowrateofemergencyroomvisits.36Acrosssuchstandardmeasuresashospitaladmissionsper1,000residents,averagelengthofstay,andhospitalreadmissions,thestateperformsclosetothenationalaverage.Therearealsoafewoutliersintheotherdirection,forexample,thestateranks40thintheratio of specialist visits to PCP visits.37

Importantly,Minnesotaperformsnearorworsethanthenationalaverageinmostoftheavailablemeasuresofunitcosts,evenwhencontrollingasmuchaspossibleforwageindexandcasemix.Forexample,thestateranked36thinboththecostperinpatientdischargeandforweightedaverageMedicarereimbursementperdiagnosisrelatedgroup,orDRG,astandardizedclassificationofservicesprovidedinahospitalsetting.38Perhapsmostnotably,thestateranked46thintheaveragecostforthe100mostfrequentlyperformedproceduresconductedinanoutpatientsettingandreimbursedthroughcommercialinsurance.39Whilethisisnotaperfectmeasure(itdoesnotcontrolforcasemixorforvariationsinbillinglevelsbyproceduretype),itsuggeststhatphysiciansinMinnesotachargemoreonaverageperprocedurethantheircounterpartsinotherstates.Therelativelyhighercommercialcostssuggestthatsomecostshiftingmaybetakingplace,asproviderschargemoreforpatientscoveredbycommercialplanstocompensateforrelativelylowgovernmentrates.

19

Exhibit 9: State of health care reform efforts

State Rank

11-2021-3031-40 1-1041-515.1

MN Value


Percent of community pharmacies e-prescribing activated

97% 95% 2013 4

2Percentage of office-based physicians using EMR/EHR 76% 48% 2013

HIT adoption

Percent of physicians routing prescriptions electronically 99% 73% 2013 1

Percent of Medicare FFS beneficiaries attributed to a Medicare ACO

19.0% 10.6% 2014 10

System initiatives

Bundled Payments for Care Improvement (BPCI): Percent of eligible providers that are participating in program

4.3% 10.4% 201337

Transparency of Physician Quality Information (Score on HCI3's State Report Card)

69 2 2013 1

5.2

Medicaid expansion

Percent change Pre-Open Medicaid Enrollment (Monthly Average) to July 2014

20.6% 13.6% 2014 14

5.3

State of health care exchanges5.4

25Ratio of unique carriers on the exchange : carriers in the individual market in 2012

83% 86% 2014

1Minimum price premium for a single 27-year old as % of average state income - Silver

$126 $188 2014

Latest marketplace QHP selection total as percent of Non-elderly (0-64), non Medicaid-eligible uninsured population

17% 29% 2014

State Rank: 5Status of health care reform efforts*5


19

Comparingstates’performanceinimplementinghealthcarereforminitiativesiscomplicatedbyanumberoffactors.Notallstatesaredoingthesamethings,andtheyarestartingfromverydifferentpointsofdevelopment,workingwithdifferentlevelsofresources,andfacingdifferentchallenges.Further,imprecisionintheavailablemeasurescreatesatendencytomeasureactivityratherthan outcomes.

Aspreviouslynoted,Minnesotapassedandimplementeditsownreformlawin2008,andhassinceembracedthevoluntarycomponentsoffederalreform,optingtoexpandMedicaidandtodevelopastate-levelhealthcareexchange.

20

Thecomparativedatareflecttheimpactofthesemanyyearsofprivateandpublicsectorinnovation,particularlywithrespecttoqualitymeasurementandreporting,andadoptionofHIT.Minnesotaperformsparticularlywellonindicatorsoftransparencyandpublicreporting.40 The state has the highestrateofphysiciansroutingprescriptionselectronicallyofanystateinthecountry,andthesecond-highestrateofphysiciansusingelectronicmedicalrecords(EMRs).41

Minnesotaalsoshowsarelativelyhighlevelofadoptionofvalue-basedpaymentmodels.ItistenthinthenationintheshareofMedicarebeneficiariescoveredbyMedicareACOs,42and43%ofthestate’sprimarycarepracticesarecertifiedasmedicalhomes.43Thiscompareswith10%ofprimarycarepracticescertifiedasmedicalhomesnationwide.44Uptakeinprogramsbaseduponepisode-basedpaymentmodelshasbeenlowinthestatecomparedwiththenationalaverage.45

Themeasurespertainingtothestate’sperformancewithfederalhealthcarereformpaintamixedpicture.Thestateexchangeappearstobeclosetothenationalaverageincompetitiveness,butisdistinguishedbyalowproportionofplansontheexchangewithnarroworverynarrownetworks.46 Minnesotaalsohasthelowestminimumpremiumsontheexchangeofanystate.(Premiumsareexpectedtoincreasesignificantlyin2015.)47, 48MeasuresofmarketenrollmentrelativetothetotalpotentialmarketforexchangeproductsranksMNsureashavingoneofthelowestpenetrationratesinthenation,butthiscanbeexplainedbythestate’shistoricallyhighratesofhealthinsurancecoverage.49Similarly,thechangeinmonthlyMedicaidenrollmentrelativetopre-openenrollmentdidnotsubstantiallyexceedthenationalaverage,asMinnesotahadinplaceverygenerousMedicaideligibilitylevels,andactedonMedicaidexpansionsoonerthanothers.50

Thescorecarddoesnotreflectthedifficultiesthatthestatehadindevelopingandimplementingthestateexchange,MNsure.Aswithseveralotherstatesthatoptedtobuildtheirownstate-basedexchanges(aswellasthefederalgovernment),Minnesotaexperiencedanumberofcostlydelaysandtechnicaldifficultiesintheinitialrolloutoftheexchange.Whilemanyoftheseinitialchallengesarebeingaddressed,operationalissuesandlonger-termchallengespersist.

21

3. STRENGTHS AND OPPORTUNITIES

TheperformancescorecardhighlightsmanystrengthsofMinnesota’shealthcaresystem.Italsopointstosomegapsandareaswhereperformancemightbeimproved.Thefollowingsectionofthereportdescribesthekeythemesthatemergefromasystematicassessmentofthescorecarddataandthird-partyresearchonMinnesota’shealthcaresystem.Therearefourareasofgenuinedistinctivenessinthehealthcaresystemthatweshouldseektoprotectandbuildupon,andfourareaswheretherearesignificantopportunitiesforimprovement.

Areas of distinctiveness

Theresearchhighlightsthesystem’sfourdistinctivestrengths,whichwarrantparticularattentionasthestateproceedswiththeimplementationofhealthcarereform.Thesefourstrengthsare:

• Nation-leadinghealthcarecoverageandaccess

• Advancedmeasurementandreportinginfrastructure

• Ahighdegreeofcarecoordinationandsystemintegration

• Generallyhighqualityofcareandpopulationhealth

Coverage and accessMinnesotaisanationalleaderinhealthcarecoverageandaccess.Ithasconsistentlymaintainedoneofthehighestcoverageratesofanystateinthecountry,thankstohighratesofcommercialcoverageandverygenerouseligibilityrequirementsforstate-subsidizedhealthinsurance.CoverageratesandaccesshaveimprovedevenfurthersincethepassageoftheAffordableCareAct.Minnesotawas1of15states(andtheDistrictofColumbia)tobothimplementastate-basedhealthinsuranceexchangeandexpandMedicaid.Thestate’scurrenteligibilitylevelsforMedicaid(205%ofFPL)areamongthecountry’smostgenerous,toppedonlybytheDistrictofColumbia.51

BetweenthelaunchofMNsureonOctober1,2013,andMay1,2014,180,000uninsuredMinnesotansgainedhealthinsurancecoverage,representinga40.6%reductioninthestate’suninsuredrate.Thepercentofstateresidentsthatareuninsuredfellfrom8.2%to4.9%,thelowestrateinstaterecords.

Whilecoverageandaccesstocarehaveimproved,thankstotheseactions,itwillbeimportanttomonitorbothasthemarketadjuststonewregulationsandpricingstructures.Aselsewhereinthecountry,Minnesotamightexperiencechurnbetweencoveragecategories,andcouldyetseeashiftawayfromemployer-sponsoredinsuranceintotheindividualmarket.Further,changesinplandesign—includingcoveredbenefitsandcostsharing—couldhaveaharmfuleffectonaccesstocare,evenamongtheinsured.

Measurement and reporting infrastructureMinnesotaisapioneerinthemeasurementandreportingofhealthcaredata.Thestate’sveryhighratesofhealthinformationtechnology(HIT)adoptiontellonlypartofthestory.Thankstotheremarkablepartnershipestablishedbetweenthepublicandprivatesectorsinthisarea,Minnesotahasbeenattheforefrontofdevelopingandreportinghealthcarequalitydata.

Minnesota’smodernhealthcaremeasurementandreportinginfrastructurehaditsoriginsinthehealthcarereformeffortsoftheearly1990s,andthepublic–privatepartnershipthatwasestablishedatthetimetoimprovethequalityandcost-effectivenessofhealthcareservices.ThispartnershipledtothecreationoftheInstituteforClinicalSystemsImprovement(ICSI),theMinnesotaHealthDataInstitute(MDHI)and,intheearly2000s,MinnesotaCommunityMeasurement(MNCM).InitiallysponsoredbythehealthplansbehindICSI,MNCMpublishedastatewidereport—thefirstofitskind—assessingtheperformanceofeachindividualmedicalgrouponastandardsetofqualityofcaremeasures.

22

Minnesota’smeasurementandreportingmovementwasfurtheradvancedwiththeHealthCareReformActof2008,andthecreationoftheStatewideQualityReportingandMeasurementSystem(SQRMS).SQRMSrequiresphysicians,clinics,andhospitalstosubmitthedataneededtocalculateperformanceonaspecifiedsetofqualityindicators.TheadoptionofSQRMSasastatewidestandardledtotheadoptionofthemeasurementplatformthatprovidersandplanshadagreedtouseinpublicreportingandledstateprogramstopayforqualityprograms.Asaresult,Minnesotaisintheenviablepositionofhavinga“commonscorecard”withwhichtocompareperformance.

Beyondthecollectionofqualityandcostdata,Minnesotaisalsoapioneerindevelopingqualityandcost-of-caremeasures,severalofwhichhavebeenendorsedbytheNationalQualityForum(NQF)andadoptednationally.52Theseadvancesinmeasurementandreportinghavelaidacriticalfoundationfortheshifttoamoretransparent,value-basedhealthcaredeliverysystem.Continuedpartnershipbetweenthestate’spayers,providers,andpolicymakerswillberequiredtoensurethatthesemeasuresareusedoptimallyindevelopingandimplementingnewaccountable-caremodels,andtocontinueadvancingthestate’smeasurementsystem.

Care coordination and system integrationMinnesota’shealthcaresystemischaracterizedbyahighdegreeofintegration.Thehealthcarelandscapeisdominatedbylargeintegrateddeliverysystems(IDSs)andhealthmaintenanceorganizations(HMOs).Thereisalsoahighdegreeofphysicianconsolidation,primarilythroughemploymentinlargemedicalgroups.53

Thestate’slargeIDSsandHMOshavehistoricallydrivenmuchoftheinnovationinthehealthcaresector,andhaveplayedaprominentroleinadvancinginnovativepaymentanddeliverymodelsinthestate.Forexample,AllinaHealth,FairviewHealthSystems,andParkNicolletHealthServices(whichrecentlymergedwithHealthPartners)makeup3ofthe19MedicarePioneerACOs.OnlyMassachusettsandCaliforniahavemoreACOsinthePioneerprogram.54

Minnesotahasalsobeenaleaderinthedevelopmentofhealthcarehomes.Commercialpatient-centeredmedicalhomes(PCMHs),suchasHealthPartners’BestCareprogram,wereamongtheearliestinthenation.Thestatehasoneofthecountry’smostcomprehensivemedicalhomecertificationandtrainingprograms,andnearlyhalfofitsprimarycarepracticeswerecertifiedbytheendof2013.

ProgramstoimprovetransitionalcareandcoordinationofservicesforspecialneedspopulationsareadditionalexamplesofMinnesota’sinnovationincarecoordinationandintegration.Thestate’sdual-eligiblesintegrationprograms,forexample,areamongthecountry’smostsuccessfulandlongestrunning.In1995,MinnesotabecamethefirststatetoreceiveCMSapprovalforapaymentdemonstrationthatallowedfullyintegratedMedicareandMedicaidmanagedcarecontractsandfinancingtocoverprimary,acute,andlong-termcareservicesforseniorsintheMinneapolis-St.Paulmetroarea.Sincethen,thestatehasdevelopedanumberofprogramsthatexperimentwithdifferentapproachestoprovidingcareforthispopulation.55

23

High-quality care and health outcomesFinally—andmostimportantly—Minnesota’shealthcaresystemisdistinguishedbyitsperformancedeliveringhighqualitycareandhealthoutcomes.Itrankedfirstinthecountryinpopulationhealthandinhealthoutcomes,inthemostrecentAmerica’sHealthRankings.

Notablehighlightsincludethelowestratesofinfantmortality,yearsofpotentiallifelostbeforeage75,andrateofmortalityamenabletohealthcareinthecountry.

Theseoutcomesreflectthehighqualityofcareprovidedbythehealthcaresystem,thestate’sdistinctivefocusonqualitymeasurementandreporting,andacollaborativeapproachtopopulationhealthmanagement.

ItisdifficulttobenchmarkMinnesota’sprovidersaccuratelyagainstotherstatesonthebasisofqualitybecausethereissomuchvariationinthevolume,quality,andconsistencyofreporting.Whilethequalityofcarevarieswithinthestate,thereisnoquestionthatMinnesotaishometoanumberofleadingmedicalresearchandprovidersystems,andthatthebestcareinMinnesotaisamongthebest available.

Ofcourse,thehealthofthepopulationdependsonmorethanjustgoodhealthcare.Recognizingthis,publicandprivatesectorleaders,bypromotingwellnessandpreventionprograms,haveshownacommitmenttoimprovingnotonlycaredelivery,butalsohealthoutcomes.Minnesota’shospitalsandhealthplansareworkingcollectivelyoncommunitybenefitandcollaborationplanstostreamlineandleverageeachother’seffortsinpopulationhealthimprovement.AnothersignificanteffortistheStatewideHealthImprovementProgram(SHIP),createdbythe2008ReformAct,whichischargedwithimprovingoverallpopulationhealththroughcommunity-basedprograms.

Opportunities for improvement

WhileMinnesota’shealthcaresystemhasmanystrengths,italsohassomenotablegapsandopportunitiesforimprovement.Theseincludetheopportunitiesto:

• Reducegrowthinhealthcarespending

• Addressgapsinthetreatmentofpopulationswithspecialneeds

• Addressgapsinthemanagementofpopulationhealth

• Mitigatedisparitiesinhealthcareaccessandoutcomes

Health care spendingThemostobviousopportunitiesforimprovementemergingfromthePerformanceScorecardpertaintothecostofhealthcare.Overall,Minnesotaranks22ndamongstatesacrossallmeasuresofhealthcarecost.Thisrankingshouldnotbetakenatfacevalueasevidenceofaproblem.Thepubliclyavailablemeasuresonspendingatthestatelevelareimperfect,anditisnotclearwhatthemostdesirablelevelofspendingshouldbe,asthereisarelationshipbetweenspendingandotheraspectsofsystemperformance.Ultimately,itisthebalanceacrossthedifferentcategoriesthatismostimportant.

24

Thedatasuggest,however,thatthereareopportunitiestoimproveefficiencyandbettermanagethecostofcare,andthatdoingsowillbecomeincreasinglyimportant.ThePerformanceScorecardsuggeststhattheremaybeopportunitiestoreducespendinggrowthbybetteraddressingbothutilizationandunitcosts(seeChapter2).Whatthescorecarddoesnotclearlyshowiswhythisisimportant.Addressingthespendingtrendremainsamajorpriorityasspendinglevelsaregrowingatanunsustainablerate,puttingpressureonemployersandindividualstopayforcareandstrainingthestatebudget.WhilespendinggrowthonhealthcarehasslowedinMinnesotaoverthepastfewyears—mirroringanationaltrend—thelong-termtrendisworrisome.Overthepastdecade,spendingonhealthcarehasgrownroughlytwiceasfastasstateGDP.Between2000and2012,percapitaspendingonhealthcaregrew83%inMinnesota,whilepercapitaGDPgrew41%(seeExhibit10).

Exhibit 10. Growth in health care spending in Minnesota

Year on year growth in per-capita health care spending (2000-2012)

Cumulative, per-capita growth in health care spending vs. state GDP in Minnesota (2000-2012)

0

1

2

3

4

5

6

7

8

9

10

2000 2002 2004 2006 2008 2010 2012

0.9%

9.3%

MinnesotaNational

% yearly growth

0

10

20

30

40

50

60

70

80

90

2000 2002 2004 2006 2008 2010 2012

Health careState GDP

% cumulative growth (nominal)

83%

Source: McKinsey Health Care Value Analytics and third party data sources; U.S. Bureau of Economic Analysis; Minnesota Department of Health: Minnesota Health Care Spending and Projections, 2012

41%

3.2%

25

Anumberofprivateandpublicsectorinitiativesarecurrentlybeingimplementedtocontainspendinggrowth.InordertoreducecostsinMedicaid,forexample,thestateinstitutedcompetitivebiddingforhealthplans,addedadditionalperformancewithholdsandpaymentshiftsforplansandproviders,andbegansomedemonstrationprogramstobringfee-for-serviceMedicaidintomoreaccountableproviderorganizations.56,57

Treatment of populations with special needsSlowingthegrowthinthecostofcarewillrequiredevelopingnewsolutionsforthetreatmentofspecialneedspopulations.Aselsewhereinthecountry,long-termcare,andthetreatmentofpatientswithlong-termdisabilitiesandmentalandbehavioralhealthproblemsconsumeadisproportionateshareofMinnesota’shealthcareresources.Forexample,43%oftheMedicaidbudgetisdedicatedtothetreatmentofdualeligibles,whorepresentonly15%oftheenrolleepopulation.

ThisproblemisbynomeansuniquetoMinnesota.Whilethestatespendsmorethanothersonsomespecialneedspopulations(dualeligibles,forexample),itdoessolargelyasaconsequenceofitsinvestmentininnovativeprogramstoimprovecoordinationanddeliveryofcare.Minnesota’sprogramsfordualeligiblesareconsideredtobeamongthecountry’sbest,andthestatehastakenactiontoaddressissuesofmentalillness.58Stepsarealsobeingtakentoscreenforandmanagementalillness,especiallyamongchildren.

WhileanumberofinnovativeprogramshavebeendevelopedforthetreatmentofspecialneedspopulationsinMinnesota(byboththestateandprivatesectorpayersandproviders),itissafetosaythattheyhavenotyetsolvedtheproblemofhowtooptimallymanagecareforthesepopulations.Continuedinnovationwithcaredeliveryandmanagementmodels,aswellasnewpaymentmodels,willberequiredandwillneedtobeaccompaniedbysystematicmeasurementandreportingtoaccuratelyascertainhowdifferentprogramsareworking.

Gaps in population health managementMinnesotahasoneofthehealthiestpopulationsofanystate,andleadsthenationinseveraloutcomemeasuresofhealthandwellness.However,therearegapsandmeaningfulopportunitiesforimprovement.ThePerformanceScorecardhighlightstheopportunitytoimprovelifestylebehaviorsthataredetrimentaltofuturehealth,forexample,byreducingthefrequencyofbingedrinking.Thetrenddataalsohighlightcausesforconcerninthegrowthoftheobesityrateandintheincreasedprevalenceofdiabetes.TheobesityrateinMinnesotaremainslowerthanthenationalaverage,buthasincreasedmorethan10%inthepasttwodecades.ThepercentofadultsinMinnesotadiagnosedwithdiabeteshasnearlydoubledinthissametimeperiod,from3.5%in1994to6.5%in2010.59

Additionalopportunitiescanbefoundinthemanagementofchildhoodhealthandbroadersocialdeterminantsofhealth.Thereappearstobeanopportunity,forexample,toimproveeducationandawarenessaroundbestpracticesinmaternalandprenatalcare.In2011,14.4%ofmothersreportedsmokingduringpregnancyand8%experiencedmaternaldepression.Childhoodimmunizationratescouldalsobeimproved.60Thesegapsarewellrecognized,andprogramsareinplacetoaddressthem,butmoreremainstobedone.61

Improvingchildhoodhealthandthelong-termhealthofthepopulationwillrequireaddressingsomeofthesocialdeterminantsofhealth.Childhoodhealthislargelydeterminedbysocialfactorssuchashouseholdincomeandparentaleducation.TherateofchildpovertyinMinnesotaremainslower,at15%,thanthenationalaverage,at22%.However,therateisashighas49%inselectracialgroups.62Morethanone-thirdofchildreninthestatearelivingbelow200%ofthefederalpovertylevel.One-thirdofbabiesbornin2011weredeliveredbyunmarriedmothers,andnearlyone-quarterwereborntomotherswithahighschooldiplomaorless.

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Disparities in health care access and outcomesThestatisticsonchildhoodpovertyandothersocialdeterminantsofhealthpointtoabroaderopportunitytoaddressanumberofdisparitiesinhealthcareaccessandoutcomeswithinthestate.WhileMinnesota’shealthcaresystemscoreswellonmostdimensionsofperformanceatthestatelevel,statewidestatisticsmasksomesignificantdifferencesinhealthcareandpopulationhealthoutcomesacrossgeographiesandbetweendifferentsub-populations.

TheMinnesotaDepartmentofHealth(MDH)reportssignificantgapsbothinsocialdeterminantsofhealthandhealthoutcomesbetweenracialandethnicgroups.Thechild-povertyratevariesdramaticallyacrossracialgroups,from9%amongwhiteMinnesotansto46%amongAfricanAmericansand49%amongAmericanIndians.TheinfantmortalityrateamongAfricanAmericansandAmericanIndiansistwicethatforwhites.ThegapisparticularlypronouncedamongAmericanIndians,withmortalityratestwiceashighasthoseforwhitesbetweentheagesof1and14,andthreetimesasgreatbetweentheagesof15and44.

WesupplementedthepubliclyreporteddatareleasedbyMDHwithacounty-levelanalysisofselectindicatorsfromthePerformanceScorecardtoassessdifferencesinhealthsystemperformanceacrossgeographies.Theresultshavebeenaggregatedtoeightregions.63 As shown in Exhibit 11, there are significantdifferencesbetweenregionsacrosseachofthedimensionsofperformance.64

Thereisamarkeddifferencebetweenregionsintermsofcoverageandaccesstocare.TheNorthwesthasthelowestpercentageofitspopulation(49.5%)coveredbycommercialinsurance,comparedwiththeMetroregion(63%),andthehighestonMedicaid(22.7%),comparedwiththatintheSoutheast,whichhadthelowest(14.5%).Thenumberofpeopleperprimarycarephysicianalsovariessignificantly,fromalowof842intheSoutheasttoahighof1,818intheWestCentralRegion.

Consistentpatternsappearbetweenregionsinmeasuresofpopulationhealthandhealthcaredelivery,withtheMetroandSoutheastregionsperformingconsistentlybetterthanotherpartsofthestate.Theadultobesityrate,forexample,variesfromalowof24%intheMetroregiontoanaverageof29%inmoreruralregions.Intermsofpatientexperienceandqualityofcare,thegreatestgapisbetweentheWestCentralRegion—whichcomesinlastformostmeasuresofqualityofcare—andtheSoutheast.Thedifferenceismostpronouncedinthemeasureofoptimalcareforchildrenbetweentheagesof5and17:54%ofclinicsintheSoutheastmetthisstandard,whilejust11.3%ofWestCentralclinicsdid.

Itisimportanttonotethatthehealthofthepopulationisduetomuchmorethantheperformanceofthehealthcaresystem.Whileimprovinghealthcarecanofcourseimprovepopulationhealthoutcomesandaddresssomeofthedisparitiesoutlinedhere,othersocialandenvironmentalfactorssuchasaccesstoeducationandsteadywork,goodnutrition,andreductionincrimeplayamajorroleinmeetingthesegoals.

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Exhibit 11. Health system performance: Regional disparities

Date Central Metro NE NW SC SE SW WC MN Avg

Population (Th) 2013 732 2,919 291 203 326 498 220 190 0 5,379

1 Coverage and Access

1.1 Health care coverage% Uninsured 2013 9% 9% 9% 11% 9% 9% 10% 8% 9.1%

1.2 System capacity and accessPopulation per primary care physician 2011 1,530 1,065 947 1,627 1,458 842 1,415 1,818 1,139 Population per dentist 2012 2,081 1,394 1,638 2,217 1,930 1,790 2,167 1,995 1,603 Population per mental health professional 2013 1,197 614 787 1,262 1,308 885 1,493 1,271 768

2 Population health

2.1 Health care risk factorsDiet: % of population who are low-income and do not live close to a grocery store

2012 5% 5% 9% 10% 7% 5% 11% 7% 6%

Food environment index: Index of factors that contribute to a healthy food environment

2011 8.7 8.6 8.0 8.0 8.5 8.9 8.2 8.6 8.5

Excessive drinking: % of adults reporting either binge drinking or heavy drinking

2012 21% 19% 18% 23% 21% 17% 18% 21% 19%

Adult obesity rate: % of adults that report a BMI >= 30

2010 28% 24% 28% 29% 29% 27% 29% 29% 26%

Adult smoking rate: % of adults that report smoking >= 100 cigarettes and currently smoking

2012 18% 15% 21% 22% 16% 14% 19% 18% 16%

Physical inactivity: % of adults aged 20 and over reporting no leisure-time physical activity

2010 21% 18% 20% 25% 23% 21% 24% 24% 20%

2.3 Health OutcomesPoor or fair health: % of adults reporting fair or poor health

2012 12% 10% 13% 11% 10% 9% 12% 12% 11%

Poor physical health days: Average number of physically unhealthy days reported in past 30 days (age-adjusted)

2012 3.1 2.8 3.1 2.7 2.5 2.5 2.7 3.0 2.8

Poor mental health days: Average number of mentally unhealthy days reported in past 30 days (age-adjusted)

2012 2.8 2.6 3.1 2.7 2.3 2.7 2.1 2.8 2.6

Low birthweight: % of live births with low birthweight (< 2500 grams)

2011 6% 7% 6% 6% 6% 6% 6% 6% 6%

3 Healthcare delivery


3_2014 10 06 MBP Regional scorecard.xlsx/Scorecard (3) Page 1 of 2

Physician Office: Getting care when needed: % of patients who gave the most positive rating possible

2013 60% 59% 61% 59% 59% 58% 60% 59% 59%

Physician Office: % of patients who gave the provider the most positive rating possible

2013 79% 79% 80% 77% 79% 80% 76% 78% 79%

3.2 Quality of careOptimal Care: Asthma - Children (5-17) 2013 48% 48% 43% 14% 32% 54% 25% 11% 44%Optimal Care: Asthma - Adults (18-50) 2013 39% 42% 31% 12% 22% 39% 18% 10% 36%Optimal Care: Diabetes - the D5 2013 34% 40% 30% 29% 36% 38% 33% 26% 36%Optimal Care: Diabetes - Blood Pressure Control 2013 81% 85% 81% 80% 84% 82% 81% 76% 83%

Optimal Care: Vascular disease 2013 47% 53% 43% 44% 54% 53% 45% 40% 49%Colorectal Cancer Screening 2013 65% 66% 63% 53% 62% 65% 58% 55% 63%Depression: 6-month remission 2013 5% 7% 5% 2% 5% 8% 4% 2% 7%Depression: 12-month remission 2013 5% 5% 6% 3% 4% 8% 3% 2% 5%Depression: 6-month response 2013 9% 12% 10% 5% 8% 13% 6% 4% 11%Depression: 12-month response 2013 8% 8% 10% 6% 7% 13% 5% 2% 8%Depression: Use of PHQ-9 2013 67% 68% 60% 51% 69% 72% 59% 45% 64%

4 Healthcare cost

4.2 UtilizationHospital admissions per 1,000 residents 2012 75 110 155 92 76 183 69 55 108 Medicare preventable hospital stays (Ambulatory Care Sensitive Conditions)

2011 57 45 49 57 54 50 54 47 49

4.3 Unit costCost per inpatient discharge adjusted for wage index and case mix ($Th)

2012 $ 19.0 $ 14.0 $ 29.2 $ 21.5 $ 30.4 $ 25.0 $ 26.6 $ 22.3 $ 15.4

3_2014 10 06 MBP Regional scorecard.xlsx/Scorecard (3) Page 2 of 2

LowestValue HighestValue

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4. THE PATH FORWARD

ThestrengthsandopportunitieshighlightedbythePerformanceScorecardpointtoseveralactionsthatshouldbetakentocontinuetheimprovementofthehealthcaresystem.Muchworkisalreadyunderway.Thefollowingoutlinessomeofthosemajorinitiativesaswellasactionsthebusinesscommunitycantakeinpartnershipwiththestatetonavigatereformandoptimizetheseefforts.

Next steps in health care system reform

Implementationofthe2008ReformActhasbeenlargelycompleted,thoughworkremainswithsomekeyinitiatives.ThecreationofastatewideHealthCareHome(HCH)model,forexample,hasbeengenerallysuccessful,butpenetrationremainslowinsomeregions,andthestateisworkingwithproviderstoaddressadministrativeconcernsandcontinuetopromotetheprogram.65TheStatewideHealthImprovementProgram(SHIP)hasestablishedanumberofpartnershipsbetweenstateandlocalgovernmentagenciestopromotecommunity-basedpopulationhealthprograms.Demonstratingthevalueoftheseprogramshasprovendifficult,however,andSHIPisfacingsignificantfundingchallengesthatwillneedtobeaddressed.66Finally,thestate’sProviderPeerGroupingprogramwassuspendedinfavorofotherinitiativesthatmeasurecostandquality,andthestatehascommissionedastudytodeterminegovernanceandalternativeusesfortheAllPayer’sClaimsDatabase(APCD).

Implementationoffederalhealthcarereformalsocontinues,andwillrepresentasourceofuncertaintyinthemarketasthestagedimplementationofkeyprogramsproceedsandtherepercussionsofregulatorychangesworktheirwaythroughthesystem.TheindividualandsmallgroupmarketswillcontinuetoundergochangesandMinnesotawillneedtoensurethatitshistoryofstrongcoverageandemployerparticipationcontinuesasthemarketadjuststothenewmandates,benefits,taxesandregulatorychanges.

Finally,thehealthcaresystemisevolvingthroughextensiveexperimentationwithnewpaymentandcaredeliverymodels.Thisexperimentationhasbeendriveninpartbytheprivatesectorandemployers,aswellasstateandnationalprograms.Buildinguponthefoundationoftheirpreviousinitiatives,manyofthesameorganizationsthathelpeddrivehealthcaresystemreforminMinnesotaoverthepasttwodecadesarecurrentlyworkingtopromotegreateradoptionofaccountablecaremodels.Theyarealsoworkingtoadvancepopulationhealthinthestatethroughcommunityhealthpartnerships,innovativecaremodels,andemployerwellnessprograms.

Recommendations

ThemanyreformsandinitiativesunderwayinMinnesotahavecreatedadynamicyetuncertainenvironmentforemployersandconsumers.Tohelpthebusinesscommunityanditspublicsectorpartnersmakethemostofthepromiseofreformandnavigatethechallengesthatitpresents,weproposesixbroadrecommendations.Theserecommendationsarebasedonafewguidingprinciples

• TheymustaddressthegapsandopportunitiesoutlinedinChapter3ofthisreport:reducegrowthinspending,addressgapsinpopulationhealthandthetreatmentofpopulationswithspecialneeds,andmitigatedisparitiesinhealthcareaccessandoutcomes

• Theyshoulddosoinwaysthatpromotecoreprinciplesofmarketefficiency,transparency,andconsumer choice

• Theyshouldharnesstheuniquecapabilitiesoftheprivatesectortocontributetoimprovingthehealthcaresystemandfosteringhealthiercommunities

• Theyshouldpromotecoordinationinordertomanagethecomplexityofthemanyreformsandoverlappinginitiativesplannedandcurrentlyunderway

Theserecommendationsarenotcomprehensive.Theyareintendedtoprovideemployerswithasetofdiscreteactionsthattheycantakecollectivelytoacceleratereform.

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Recommendation 1: Advocate to extend existing public–private partnerships for health care measurement to address gaps, better assess disparities, and promote greater accountability for providing affordable, high-quality care.Thankstoauniquehistoryofcollaborationbetweenthepublicandprivatesectors—anddrivenbyasustainedcommitmenttoimprovingquality,choice,andmarketefficiency—Minnesotahasoneofthecountry’smostrobustqualitymeasurementandreportinginfrastructures.Thisassetenablescontinuousimprovementsinthequalityofcare,supportsmeaningfulconsumerchoice,andlaysthefoundationforeffectiveaccountablecaremodels,inwhichprovidershavedirectresponsibilityforthecostaswellasthequalityofthecaretheydeliver.

Asimpressiveasthestate’smeasurementandreportingsystemsare,therearethreemajorwaysinwhichtheymightberefined.

First,thequalitymeasurementstandardsshouldbeexpandedtoaddressrecognizedgapsandomissions.Thisexpansionshouldstartwiththeadoptionofmoresystem-levelmeasuresofchildren’shealth.Therearecurrentlyveryfewsystemwidemeasureswithwhichtoaccuratelyassesschildren’shealthandthequalityofhealthcareservicestochildren.MinnesotaCommunityMeasurement(MNCM)collectssomegoodmeasuresonpreventionservices,andthestatehasdevelopedapatient-reportedoutcomemeasureforAsthma.Minnesotashouldbuildonthisexperiencetodevelopmeasuresforotherimportantareasforchildrenandtheirfamilies,includingpatientexperience,mentalhealth,riskysubstanceuse,andinjuryprevention.Addressingthisgapwillhelptoestablishanempiricalfoundationforthedevelopmentofmoreeffectivechildren’shealthprograms,andhelptargetandreducedisparitiesinchildren’shealthoutcomes.

Second,thestate’sexcellentmeasurementandreportingsystemshouldbeextendedtoincludetheperformanceofcommunity-basedpopulationhealthprograms.Effectivepopulationhealthprogramswillbeanessentialcomponentofanyplantoreducethelong-termcosttrendandmitigatedisparitiesinhealthoutcomes.Unfortunately,theseprogramsarenotoriouslydifficulttoevaluate,sodeterminingwhichprogramsareworkingandwhicharelesseffectiveisoftenverydifficult.Definingacommonsetofmeasurementstandardsandreportingconventions–includingtheassignmentandrecognitionofaccountability-willhelpstandardizeprogramevaluationandfacilitatetheidentificationandreplicationofthemosteffectivemodels.

Finally,thestandardsshouldbeexpandedtoincludeacommonsetofcostmetrics—startingwithastandarddefinitionofthetotalcostofcare—tosupplementexistingqualitymeasures.Thismetricwasapprovedaspartofthe2008HealthCareReformAct,butwasnotsuccessfullyimplemented.Additionalworkhasbeendonesincethenwithprovidersacrossthestatetoadoptastandardmeasureofthetotalcostofcare.Resultsofthisworkwerereleasedinlate2014.Minnesotashouldcontinuetoleadinthetestingandrefinementoftotalcostofcaremeasuresapplicabletoprimary,secondaryandcomplexcare.Theadditionofcostmeasuresofthiskindtothecurrentlycollectedqualitymeasureswillbeanessentialstepinpromotingmeaningfulprovidercomparisonandconsumerchoice,and–byextension–toimprovingqualityofcareandmoderatingcostgrowth.

Recommendation 2: Bring leaders in the state’s health care delivery and medical technology sectors together to partner on innovations designed to improve population health, patient experience, and affordability.PrivatesectorhealthplansandprovidersinMinnesotahavebeenadrivingforceinthecontinuousimprovementandreformofthestate’shealthcaresystem.Sincetheearly1990s,severalofthestate’sleadinghealthcareorganizationshaveworkedtogetherandpartneredwiththestatetodriveimprovementsinmeasurementandreporting,innovationincaredeliveryandpayment,systemintegration,andconsumerengagement.Thispartnershipremainsattheheartofmanyofthestate’smostambitiousandpromisingreformsandpilotprograms.

Thereisanopportunitytobuilduponthisfoundationandtofurtheracceleratemeaningful,market-basedreformbyexpandingthispartnershiptobetterincorporateotherleadinghealthcarecompaniesbasedinthestate–particularlythoseinthemedicaltechnologysector.Minnesotaishometoa

31

numberofleadinghealthcareorganizationswithanationalorglobalpresence.CompanieslikeUnitedHealthcareandMedtronic,basedinMinnesota,andothernationalorganizationswithastrongpresenceinMinnesotaandexpertiseinhealthcare,suchasBostonScientificand3M,haveavestedinterestinimprovingthehealthcaresystemandhealthinthestate,andhaveagreatdealtocontributethankstotheirextensiveexperienceinothermarkets,technicalexpertise,andresources.TheplansandproviderswhohavebeenleadingreforminMinnesotashouldworktomoreactivelyengagetheseorganizations,andleveragetheiruniquecapabilitiestoimprovepatientexperienceandpopulationhealthwhilereducingpercapitaspendingonhealthcare(theTripleAim).Sincethehealthofthepopulationisduetomorethanjusthealthcare,thispartnershipshouldextendtoaddressothersocialandenvironmentaldeterminantsofhealth,suchasaccesstoeducationandsteadyemployment.

Recommendation 3: Draw on best practices to inform consumers about their health and the health care system, and to promote greater consumer engagement.TherapidchangestakingplaceintheMinnesotahealthcaresystemcanbedifficultforconsumerstounderstand.Thisisparticularlytrueforthoseseekingcoverageinnewways.Peoplewhowerepreviouslyuninsuredorself-insuredandarenowpurchasingplansthroughMNsureorasindividualpurchasers,forexample,willlikelyexperienceanumberofmeaningfulchangesinthewaytheypurchasecoverage,thebenefitsprovidedbytheirnewhealthplan,andpotentiallyintheproviderstowhomtheyhaveaccess.Consumersneedgoodinformationonplancoverage,out-of-pocketexpenses,providernetworks,andhowtomakethebestchoicesforthemselvesandtheirfamilies.

Employersandthelargerbusinesscommunityhaveanimportantroletoplayineducatingconsumersaboutthechangesinthesystem,thechoicestheymustmake,andtheresourcesavailabletothem.Employersshouldworktogetherandwiththeirlocalprovidersandhealthplanpartnerstosharebestpracticesinemployeeeducationandcommunity-basedconsumerawarenessprograms.Coordinationwillhelppromoteconsistencyinmessagingandwillallowemployerstoleverageacommonsetofresources.

Successfullyimplemented,theseprogramswillhelpemployees,theirfamilies,andlocalcommunitiesbetternavigatethesystem,makemoreinformedchoices,andlivehealthierlives.Theywillalsohelpadvancereformsbasedontransparency,accountability,andconsumerchoice,whichdependuponinformedconsumerstoadvancequalityandvalue.

Recommendation 4: Promote best practices in employee and family wellness programs, including coordination across employers.Employersbearthebruntofrisingpremiumsforemployeesandfamilymemberscoveredbyemployer-sponsoredhealthplans,andareactivelyexploringopportunitiestoimprovetheirhealthandwellbeingwhilereducinginsuranceandmedicalcosts.Properlydesignedandimplemented,wellnessprogramscanimproveemployeehappinessandproductivitywhilereducingcosts—theexactoutcomesweaspiretoachievewiththesystemstatewide.Unfortunately,employerscurrentlyhavelimitedexposuretocasestudiesofsuccessfulprogramsandbestpracticesoutsideoftheirownorganizations.

Werecommendthatemployersestablishacollaborativelearningforumtosharebestpractices,andtodisseminateevidenceandsupportingtoolsamongthemselves.Thiscollaborationshouldincludetheadoptionofcommondatacollectionandmeasurementstandardsinordertomeasureimpactsystematicallyandaccurately.Theseeffortsshouldextendtocommunity-basedprogramswithwhichtheseemployersareconnectedinpartnershipwiththeirhealthplans.

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Recommendation 5: Partner with state agencies to produce an implementation roadmap and performance accountability framework for reform initiatives and demonstrations.Asafirststeptoplanforandnavigatereform,theprivatesectorshouldworkwiththosestateagenciestaskedwithimplementingdifferentreformeffortsanddemonstrationprojectsandcreateaunifiedimplementationroadmapandperformanceaccountabilityframework.Minnesota’shealthcaremarketisacrucibleofexperimentation,withmultipleagenciesandorganizationssimultaneouslyimplementingoverlappingprograms.Thisoverlapisparticularlypronouncedintheactiveexperimentationwithaccountablecaremodels.Theplans,providers,andpolicymakersbehindtheseprogramsareworkingtoensurecoordination.Forexample,theAccountableCommunitiesforHealthbeingdevelopedaspartoftheSIMtestinggrantbuildsontheexistingMedicaidACOdemonstration.PerformancemetricsfortheseAccountableHealthCommunitieswillbeimportanttomeasuresuccessandtoensuresustainability.Inaddition,publiclyreportedmetricsonenrollmentandeligibilityforstatepublicprogramsandMNsurecouldhelpconsumersunderstandtheprogressinmodernizingtheenrollmentsystemandMNsure’sperformance.

Recommendation 6: Share findings widely in the community to increase awareness of Minnesota’s performance in health and health care, and the efforts underway to further improve health in the state.Finally,theprivatesectorhasanimportantroletoplayinhelpingpromoteunderstandingofthestate’shealthcaresystemandawarenessofitsperformanceamongconsumersacrossthestate.Minnesotansarefortunatetoliveandworkinastatethatconsistentlyranksamongthebestinthecountryintermsofhealthoutcomesandsystemperformance.Thisisanaccomplishmenttobeproudof,andalegacytomaintain.CoordinationandengagementwillberequiredatalllevelsifMinnesotaistostayattheforefrontinpopulationhealth,andtoaddressthechallengesanddisparitiesoutlinedinthisreport.Theprivatesectorcanhelppromotethisengagementandfurtherbuilduponitsremarkablecontributionsinimprovingmeasurement,reporting,transparency,andconsumerchoice.

* * * * * * * * * * * * * * *

These recommendations represent a set of practical actions that the business community can undertake in partnership with the state to capture the opportunity presented by the many reform initiatives underway in Minnesota. Together, they will help ensure that reforms address the most important opportunities for improvement, while promoting transparency, efficiency, and options for consumers. In the process, they will also help establish the foundation for the next horizon of reform, advancing accountable care, measurement, and effective community-based population health programs in order to improve outcomes, reduce disparities, and manage costs.

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PERFORMANCE SCORECARD

State Rank:

State rank represents a forced ranking of 1-51 for each state and the District of Columbia Ranking is based on normative metrics, with a rank of 1 indicating best performance The ranks are color coded as follow:

Distribution of Metrics:

The distribution of normative metrics are shown across performance quintiles Performance is scored so that it is preferable to be in the top quiintile (1) for any metric The concentration of metrics by quintile within a given domain is represented by the size of the circles, with larger circles indicating a greater concentration of metrics.

Legend

76-100% of metrics 51-75% 26 -50% 1-25% 0%

1-10State Rank: 11-20 21-30 31-40 41-51

1(Top)

2 3 4 5(Bottom)

Category

4

5

State Total

Coverage and access

Population health

Health care delivery

Health care cost

Status of health care reform e�orts

1

2

3

Category-weighted state average

1.1

2.1

1.2

2.2

2.3

3.1

3.2

4.1

4.2

4.3

5.1

5.2

5.3

5.4

Health care coverage


Prevalence and incidence

Health care risk factors

Health outcomes

Patient experience

Total cost of care

HIT adoption

System initiatives

State health care exchanges

Medicaid expansion

Unit cost

Utilization

Quality of care

Aggregate system scorecardHealth system performance scorecard

Health system performance framework Distribution of metrics by performance quintile (1-5)

2

4

State rank (1-51)

Domain

Source: McKinsey Health Care Value Analytics and third-party data sources

1

1

24

4222

425

1 82

6

11

13

5

1

12

7

12

3

2

Totalmetrics

Numbers in the circle represent individual performance metrics

2

48% 19% 10% 6%17%

2

2

4

4 2

9 2

1

4

#

1 1

3

32 1

1

32 1

31 1 1

1

31 3 2

1

4 1 3

1

1

11

4

333

2

34


1.2 System capacity and access

Performance relative to national average


Change from previous year

MN value National Average MN

SD fromNat AvgQuintileState RankNational

AvgPercent of uninsured and underinsured

Payer mix: percent uninsured

Percent with inadequate health coverage

9%

9%

15%

12%

6

3

1

1

-1.5

-1.5

-0.2%

N/A

-0.4%

N/A


MN valueNational Average MNSD from

Nat Avg QuintileState RankNational

Avg

Coverage by type

Payer mix: percent commercial insured

Payer mix: percent Medicaid bene�ciaries

Payer mix: percent Medicare bene�ciaries

High-deductible health plans: percentage of commercial enrollment covered by HSA/HDHP

Percent of Medicaid eligible enrolled in managed Medicaid

Percent of Medicare eligible enrolled in managed Medicare (Medicare Advantage)

Indicators of health system capacity

Number of individuals per American College of Surgeons (ACS)-veri�ed trauma center (in thousands)

Number of individuals per primary care physician

Percent of population in Primary Care Health Professional Shortage Areas (HPSAs): >3,500 individuals per PCP

Percent of PCP needs met (Current number of physicians/Number of physicians needed to eliminate the HPSA status)

Number of individuals per specialist

Number of individuals per hospital (in thousands)

Occupancy rates in community hospitals

Percent of hospitals with positive net income

Average doctor o�ce wait times (in minutes)

Indicators of health system integration and consolidation

System integration: percent of physicians employed by hospitals

Percent of physicians belonging to a medical group

System integration: percent of hospitals in a system

System integration: percent of hospitals in a network

Average number of physicians in a medical group

Indicators: Medicaid access

Medicaid eligibility limits for parents of dependent children: percent of federal poverty level

Medicaid eligibility limits for other non-disabled adults: percent of federal poverty level

Medicaid eligibility limits for children (0-1): percent of federal poverty level



Medicaid eligibility limits for pregnant women: percent of federal poverty level

Dual eligible enrollees: duals as a percent of Medicaid enrollment

Distribution of Medicaid enrollees by enrollment group: percent of enrollees "Aged"

1.1 Health care coverage

61%

16%

16%

14%

66%

50%

51%

19%

16%

7%

74%

29%

6

33

37

2

37

1

1

4

4

1

4

1

1.5

-0.6

-0.1

2.1

-0.4

1.9

-0.6%

0.4%

0.4%

-0.8%

2.1%

2.8%

-0.2%

1.2%

0.4%

-0.8%

2.6%

1.6%

384

1,385

7%

60%

675

40

66%

75%

16.7

4,485

1,265

20%

60%

717

63

64%

69%

20.3

14

39

9

26

13

16

17

15

7

2

4

1

3

2

2

2

2

1

-1.9

0.3

-1.0

0.0

-0.2

-0.8

0.3

0.7

-1.6

24%

58%

62%

23%

39.8

205%

0%

288%

280%

280%

283%

15%

10%

25%

40%

62%

30%

19.4

N/A

N/A

N/A

N/A

N/A

N/A

14%

9%

33

2

24

37

6

50

1

43

45

46

48

23

13

4

1

3

4

1

5

1

5

5

5

5

3

3

-0.1

2.0

0.0

-0.6

0.8

N/A

N/A

N/A

N/A

N/A

N/A

0.3

0.4

Year

2013

2012

Year

2013

2013

2013

2013

2011

2013

2013

2012

2013

2013

2012

2012

2011

2012

2013

2013

2013

2012

2012

2013

2013

2013

2013

2013

2013

2013

2010

2010

State Rank

Metric included in aggregate scorecard

Health system performance scorecard Coverage and access 1

1

1-10State Ranking: 11-20 21-30 31-40 41-51

Continued >>

35


Distribution of Medicaid enrollees by enrollment group: percent of enrollees "Disabled"

Distribution of Medicaid enrollees by enrollment group: percent of enrollees "Adult"

Distribution of Medicaid enrollees by enrollment group: percent of enrollees "Children"

14%

27%

48%

15%

27%

49%

29

14

36

4

2

4

-0.3

0.0

-0.1

2010

2010

2010

State Rank


Health system performance scorecard Coverage and access 1

1

1-10State Ranking: 11-20 21-30 31-40 41-51


Performance relative to national average Change from previous year

MN value MN National Average

SD fromNat Avg

QuintileNational State RankAvgYear

36






Year

Year

Year

National Average MNSD from


AvgEnvironmental risk factors

Air Quality Index

Injury deaths (per 100,000)

Occupational fatalities (per 100,000)

.68

59

3.3

20

11

14

2

1

2

1.1

-0.3

-0.3

0.00

1.20

0.36

0.04

0.90

-0.05

Behavioral risk factors

Percent of adults reporting excessive drinking

Percent of persons 12 and over with any illicit drug use in the past month

Percent of adults reporting no exercise in the last 30 days

Percent of adults reporting consumption of fewer than 5 servings of fruits/vegetables per day

Percent of adults who self-report as cigarette smoking

Percent of high school students reporting cigarette use in the last month

Other leading indicators of health risk

Percent of adults designated as obese (BMI ≥ 30)

Percent of children ages 10-17 designated as obese (BMI >95th percentile)

Percent of adults with high blood pressure

2.2 Prevalence and incidence


NationalAverage MNSD from


AvgChronic conditions, cancer, and common STDs

Percent of Medicare bene�ciaries with 2 or more chronic conditions

Invasive cancer incidence rate (per 100,000)

Percent of adults who have ever been told they have diabetes

Percent of adults who have ever been told they have asthma

Chlamydia case rate (per 100,000)

Gonorrhea case rate (per 100,000)

Syphilis case rate (per 100,000)

Percent of adults with mental illness

2.3 Health outcomes


National Average MN

SD fromNat Avg

QuintileState RankNational Avg

General health outcomes

Percent of adults that self-reported "poor" or "fair" health

Gallup-Healthways Well-Being Index

Mortality rates from common causes of death

Stroke deaths (per 100,000)

Alzheimer's disease deaths (per 100,000)

Heart disease deaths (per 100,000)

In�uenza and pneumonia deaths (per 100,000)

Homicide deaths (per 100,000)

Suicide deaths (per 100,000)

16%

9%

23%

76%

21%

18%

39

24

6

35

11

29

4

3

1

4

1

4

0.7

-0.3

-1.4

0.5

-0.6

0.0

-2.8%

1.2%

-4.4%

N/A

-1.9%

N/A

-0.4%

0.0%

-3.1%

N/A

-0.6%

N/A

MN value

0.81

55

2.6

18%

8%

18%

78%

19%

18%

26%

14%

22%

69%

459

9%

14%

456.7

107.5

16.0

17.8%

7

33

4

4

8

15

18

14

1

4

1

1

1

2

2

2

-1.8

0.6

-1.2

-1.6

-0.8

-0.8

-0.7

-0.1

N/A

N/A

0.3%

1.3%

19.10

14.60

-0.60

N/A

N/A

N/A

0.4%

0.3%

-0.90

3.30

1.20

N/A

28%

16%

29%

14

19

1

2

2

1

-0.6

-0.5

-2.1

0.0%

N/A

N/A

-0.2%

N/A

N/A

2013

2010

2012

2010

2011

2012

2009

2011

2011

2012

2011

2009

MN value

MN value

57%

476

7%

11%

337.8

57.7

6.3

17.4%

12%

69.7

36.1

22.2

122.1

10.3

1.8

10.8

17%

66.2

39.1

24.2

182.8

16.5

5.5

11.8

1

3

14

18

1

3

4

11

1

1

2

2

1

1

1

1

-1.5

1.8

-0.5

-0.3

-2.1

-1.6

-1.2

-0.3

-0.3%

N/A

1.7

-1.2

2.7

0.6

0.3

-0.4

0.0%

N/A

-0.5

-0.9

3.7

1.4

-0.2

0.3

2012

2009

2010

2010

2012

2012

2012

2011

2012

2013

2010

2010

2010

2010

2010

2010


Health system performance scorecard Population health 2

State Rank 1

1-10State Ranking: 11-20 21-30 31-40 41-51

Continued >>

37



Health system performance scorecard Population health 2

State Rank 1

1-10State Ranking: 11-20 21-30 31-40 41-51

Infant mortality rates and birth complications

Infant mortality rate (per 1,000 live births)

Percent of live births with low birth weight

Perinatal deaths (per 1,000 live births)

Hospital rates of early scheduled delivery: percent of mothers who indicated elective delivery as a percent of total mothers who delivered between 37-39 weeks of gestation

4.5

6.6%

4.6

27%

6.1

8.1%

6.1

17%

5

9

6

19

1

1

1

5

-1.3

-1.2

-1.2

1.7

-0.1

0.2%

N/A

N/A

-0.3

0.0%

N/A

N/A

2010

2011

2010

2010

2.3 Health outcomes


Year


MN National Average

SD fromNat Avg

QuintileNational State RankAvgMN value

38


3.2 Quality of care


Year National Average MN

SD fromNat Avg

QuintileState RankNational AvgHospital and ACO performance ratings

Hospital safety score: percent of hospitals that received a grade of "A"

Average of Medicare ACOs' performance on 5 reported quality-of-care measures

Acute/Inpatient care

Average number of minutes patients spent in the ED before they were admitted

Percent of outpatients having surgery who got an antibiotic at the right time (within 1 hour before surgery)

Percent of HF patients given ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD)

Management of chronic conditions

Percent of diabetes patients meeting target levels for modi�able risk factors (Hb1Ac, LDL, blood pressure, tobacco use)

Percent of depression patients who have reached remission (PHQ-5 score < 5) within 6 months

Controlling High Blood Pressure (BP): percent of patients 18-85 who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90)

Screening and immunization

Percent of women ages 24-64 who were screened for cervical cancer

Percent of patients ages 51-75 who were up to date with appropriate colorectal cancer screening exams

Percent of women 40-69 who had a mammogram to screen for breast cancer

Childhood immunization status: percent of 2-year-old children who had CDC-recommended 4:3:1:3*3:1:4 series of immunizations

Star Rating of Medicare Advantage plans

Medicare Part C Star Rating

Patient experience with public mental health system

Percent of adults reporting improved functioning from the public mental health system in the past 6 months


Year National Average MN

SD fromNat Avg

QuintileState RankNational AvgCAHPS measures of patient experience

Physician O�ce, Access to Care: percent of patients who gave the physician the most positive rating possible (State average across clinics)

Physician O�ce: percent of respondents that gave their provider a top rating of 9 or 10 on a 10-point scale (State average across clinics)

Physician O�ce:, provider-patient communication: percent of patients who gave the most positive rating possible (State average across clinics)

Physician o�ce, courteous and helpful o�ce sta�: percent of patients who gave the most positive rating possible (State average across clinics)

Hospital: percent of patients who reported "YES," they would de�nitely recommend the hospital (State average across hospitals)

60%

78%

90%

91%

72%

N/A

N/A

N/A

68%

N/A

N/A

N/A

39

N/A

N/A

N/A

N/A

N/A

N/A

N/A

-0.5

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

3

34

29

1

5

4

-1.3

N/A

N/A

275

99%

97%

35%

1.00

21

1

3

1

-0.3

2.4

N/A

N/A

N/A

N/A

71%

N/A

N/A

N/A

N/A

17

N/A

N/A

N/A

N/A

2

N/A

N/A

N/A

N/A

0.3

2012

2012

2012

2012

2013

29%

1.24

199

98%

96%

38%

7%

75%

72%

69%

73%

66%

4.5

80% 70% 5 1 1.3

3.6 2 2.01

2013

2013

2013

2012

2013

2013

2013

2013

2013

2013

2013

2012

2011

2013

MN value

MN value




Health system performance scorecard Health care delivery3

State Rank 4

1-10State Ranking: 11-20 21-30 31-40 41-51

39



YearNational Average MNSD from


AvgPer capita health care spending: all payer types

Per capita personal health care expenditures by state of residence

Per capita hospital expense

Health care spending: Commercial

Total family premiums per enrolled employee at private sector establishments (average in dollars)

Total premiums for private sector employees enrolled in single coverage (average in dollars)

Total family premiums per enrolled employee at private sector establishments (average in dollars) as a percent of median household income

Total medical costs per member per month for commercial health plans (state average in dollars)

Health care spending: Medicare

Health care spending: Medicaid

Total Medicare reimbursements per enrollee

Part D spending per Medicare bene�ciary

CMS Medicare hospital spending per patient (indexed to Medicare spending per patient on hospital care nationally)

Medicare spending per decedent during the last 2 years of life

Dual eligible enrollees: Duals' share of Medicaid spending

Medicaid expenditure as a percent of total state expenditures

Change in Medicaid expenditure as a percent of change in state GDP

Medicaid per enrollee payments: Total population

Medicaid per enrollee payments: Adults

Medicaid per enrollee payments: Children

Medicaid per enrollee payments: Aged

Medicaid per enrollee payments: Blind/disabled

4.2 Utilization


Nat Avg QuintileState Rank

National Avg

General inpatient and emergency room care

Hospital admissions per 1,000 residents

Hospital emergency room (ER) visits per 1,000 residents

Average length of stay

Commercial: Acute hospital admissions per 1,000 members

Readmissions

All-cause 30-day Medicare readmission rate

Rate of 30-day readmission for heart failure patients

Rate of 30-day readmission for pneumonia

Rate of 30-day readmission after all surgical stays

Scanning and diagnostics

Percent of outpatients with low back pain who had MRI without trying other treatments

Outpatients with brain CT scans who got a sinus CT scan at the same time

Outpatient CT scans of the chest that were combination (double) scans

$7,409

$2,801

$15,408

$5,338

24.9%

$284

$7,646

$1,927

0.90

$58,963

$6,230

$3,845

$3,209

$22,996

$28,440

43%

28%

3%

108.4

352.9

6.0

57.9

17.6%

19.7%

13.7%

10.7%

50.9

2.6

2.4

36.5

2.8

3.7

51

25

20

5

3

2

3.7

-0.3

-0.6

N/A

N/A

N/A

N/A

N/A

N/A

19.1%

21.1%

15.3%

12.4%

21

17

11

14

2

2

1

2

-0.7

-0.9

-1.1

-1.3

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

109.7

424.4

5.4

56.2

25

11

37

30

3

1

4

3

0.0

-0.6

0.6

0.3

-3.1

-7.9

0.0

0.64

-2.1

8.9

0.0

0.04

2013

2013

2013

2011

2010

2010

2010

2012

2012

2012

2012

$4.192

$3,264

$2,090

$11,500

$17,591

36%

24%

3%

44

25

43

40

43

37

42

35

5

3

5

5

5

4

5

4

1.4

0.5

1.7

2.0

2.0

0.9

0.7

0.6

-$2,025

$189

$266

$1,429

-$741

N/A

N/A

0.1%

-$ 1,710

$212

$91

N/A

$448

N/A

N/A

-0.1%

5

1

5

17

1

1

1

2

-1.7

-2.3

-1.6

-1.2

N/A

N/A

N/A

N/A

$9,584

$2,670

0.98

$69,947

N/A

N/A

N/A

N/A

$15,473

$5,384

30.3%

$291

27

24

4

22

3

3

1

3

-0.1

-0.1

-1.3

-0.1

-$131

-$88

-1.9%

$20

$451

$162

0.3%

$8

$6,815

$2,411

36

38

4

4

0.6

0.5

N/A

$93

N/A

$158

2011

2011

2011

2011

2011

2010

2012

2011

2010

2010

2013

2010

2012

2012

2012

2013

2009

2012

MN value

Year MN value






Health system performance scorecard Health care cost4

State Rank 22

1-10State Ranking: 11-20 21-30 31-40 41-51

Continued >>

40


4.3 Unit cost




AvgRelative unit costs: Commercial

Commercial reimbursement per CPT: index of payment for 100 most-common physician o�ce-based procedures

Commercial reimbursement per diagnosis-related group (DRG): index of payment for 100 most-common DRG discharges

Cost per acute inpatient admission

Medicare Inpatient Prospective Payment System (IPPS) Geographic Adjustment Factor (GAF) (average of urban area-level weighted by Medicare discharges)

Weighted average Medicare reimbursement per DRG

Hospital expenses per discharge: all payer types

Cost per inpatient discharge adjusted for wage index and case mix

1.00

1.00

42

36

5

4

1.2

0.2

N/A

-1.0%

N/A

0.0%

1.00

1.00

$15,735

46

33

22

5

4

3

1.4

0.3

-0.5

-0.05

-0.02

-$509

0.00

0.00

-0.3

1.39

1.05

$14,611

1.06

1.03

$15,445 $13,731 36 4 0.6 N/A N/A

2012

2012

2012

2012

2012

2011

Relative unit costs: Medicare

Year MN value


State Rank


Health system performance scorecard Health care cost4

1

1-10State Ranking: 11-20 21-30 31-40 41-51

22

Other

Ratio of specialist visits : PCP visits

Discharges for Ambulatory Care-Sensitive Conditions per 1,000 Medicare enrollees

Percent of Medicare decedents seeing 10 or more di�erent physicians during the last 6 months of life

Medicare Generic Dispensing Rate (GDR)

1.4

50.6

34

81

1.3

66.6

42

74

40

8

20

1

4

1

2

1

0.2

-1.1

-0.8

2.3

0.3

N/A

N/A

N/A

0.0

N/A

N/A

N/A

2012

2010

2010

2010

4.2 Utilization


Nat Avg QuintileAvg State Rank

National Year MN value


41


5.4 State of health care exchanges


National Average MN

SD fromNat Avg

QuintileState RankNational AvgEnrollment of eligible population

Latest marketplace QHP selection total as percent of non-elderly (0-64), non-Medicaid-eligible uninsured population

Health insurance marketplace enrollment as a share of potential marketplace population

Exchange competitiveness

Number of insurers in the individual health insurance marketplace

Ratio of unique carriers on the exchange : carriers in the individual market in 2012

Product and network design of plans on the exchange

Product design: HMO and EPO products as % of all plans on the exchange

Network design: products with narrow networks as % of all plans on the exchange

59%

46%

34

42

4

5

-1.1

-1.2

4.00

86%

19

25

3

3

0.3

-0.1

29%

28%

46

43

5

5

-0.7

-1.0

17%

16%

5.00

83%

22%

17%

2014

2014

2014

2014

2014

2014

Year MN value

Performance relative to national averagePerformance relative to national average Change from previous year

MN

5.3 Medicaid expansion

National Average

SD fromNat Avg


Percent change Pre-Open Medicaid Enrollment (monthly average) to July 2014

Percentage drop in uninsured (2010-2014)

13.6%

3%

14

17

3

4

0.4

-0.6

20.6%

1%

2014

2014

Year MN value



Health system performance scorecard State of health care reform e�orts5

1-10State Ranking: 11-20 21-30 31-40 41-51


National Average MN

SD fromNat Avg


Penetration of value-based care models

HIT adoption

Percent of primary care practices that are Patient-Centered Medical Home (PCMH)-certi�ed

Percent of Medicare FFS bene�ciaries attributed to a Medicare ACO

Bundled Payments for Care Improvement (BPCI): percent of eligible providers participating in program

10.0%

10.6%

10.4%

N/A

10

37

5

1

4

N/A

0.7

-0.6

43.0%

19.0%

4.3%

2013

2013

2013

Year MN value


Transparency of Physician Quality Information (score on HCI3's state report card)

Transparency and public reporting

Medicaid expansion

69 2 1 1 3.92013

Accountable care organizations (ACOs)

Number of commercial and Medicare ACOs

Number of Medicare ACOs

9

7

459

365

20

17

3

2

2013

2013

N/A

N/A

State Rank 5

Continued >>

Metric included in aggregage scorecard5.1 HIT adoption

Year MN value National Average MNSD from


Avg

Percent of o�ce-based physicians using EMR/EHR

Percent of physicians routing prescriptions electronically

Percent of community pharmacies with e-prescribing activated

76%

99%

97%

48%

73%

95%

2

1

4

1

1

2

2.3

2.2

1.1

8.8%

19.0%

3.0%

8.5%

4.0%

2.0%

2013

2013

2013


Product pricing by metal tier

Minimum price premium for a single 27-year old as % of average state income - Catastrophic

Minimum price premium for a single 27-year old as % of average state income - Bronze

$80

$95

$126

$149

2

1

1

1

-1.2

-1.2

2014

2014

42


Enrollment by metal tier

Percent of marketplace enrollment under Bronze plan

Percent of marketplace enrollment under Silver plan

Percent of marketplace enrollment under Gold plan

Percent of marketplace enrollment under Platinum plan

Percent of marketplace enrollment under Catastrophic plan

25%

34%

12%

27%

1%

20%

65%

9%

5%

2%

12

49

20

1

24

2

5

3

1

5

0.7

-2.5

0.6

3.3

-1.1

2014

2014

2014

2014

2014

Minimum price premium for a single 27-year old as % of average state income- Silver

Minimum price premium for a single 27-year old as % of average state income - Gold

Minimum price premium for a single 27-year old as % of average state income - Platinum

2014 monthly premiums for a single 40-year old at 250% of FPL in a major city (benchmark plan)

2014 monthly premiums for a single 40-year old at 250% of FPL in a major city (second-lowest cost Silver plan after subsidies)

2014 Monthly premiums for a single 40-year old at 250% of FPL in a major city (Lowest-Cost Bronze Plan Before Subsidies)

2014 Monthly premiums for a single 40-year old at 250% of FPL in a major city (Lowest-Cost Bronze Plan After Subsidies)

$126

$147

$157

$154

$154

$115

$115

$188

$214

$254

$258

$193

$202

$130

1

1

1

1

1

1

10

1

1

1

1

1

1

1

-1.3

-1.1

-1.3

-1.8

-4.4

-1.7

-0.9

2014

2014

2014

2014

2014

2014

2014


Health system performance scorecard Status of health care reform e�orts5

State Rank 5

1-10State Ranking: 11-20 21-30 31-40 41-51

5.4 State of health care exchanges


Year MN value National Average MNSD from

Nat Avg QuintileNational State RankAvg


43

TECHNICAL APPENDIX1. Timeline of health care reform in Minnesotacare reform in Minnesota

1988

1992

1993

2000

2005

2006

2008

2009

2010

2011

2012

2013

▪ Buyers Health Care Action Group (now called the Minnesota Health Action Group)created to represent interests of health care purchasers and promote improvement in thehealth care system

▪ MinnesotaCare program established, expanding subsidized coverage for low-incomeadults ineligible for Medicaid

▪ Institute for Clinical System Improvement (ICSI) established to promote developmentand use of evidence-based medicine

▪ Minnesota Health Data Institute (MDHI) created to improve HIT standards andinfrastructure

▪ Patient Choice Healthcare Inc. created to sort providers into tiers based on cost and qualityMinnesota Community Measurement (MNCM) formed by health plans sponsoring ICSI to publish comparative data on patient care and outcomes statewide

▪ Minnesota Buyer's Health Action Group establishes Bridges to Excellence to recognizeand reward high-performing clinics

▪ Carol.com founded as an early effort to create an online medical marketplace▪ Transformation Task Force publishes recommendations for health care reform▪ 2008 Health Care Reform Act passed▪ Statewide Health Improvement Project (SHIP) created to support community-based

population health programs▪ Work begins to create Statewide Quality Reporting and Measurement System

(SQRMS)

▪ Work begins to create All Payer Claims Database (APCD)

▪ Northwest Metro Alliance formed by HealthPartners and Alliance Health as a "learning lab" for ACOs

▪ Medicaid expanded under ACA▪ Certification of Health Care Homes (HCHs) begins▪ MN selected as 1 of 8 states to participate in the CMS Multi-Payer Advanced Primary

Care Practice demonstration

▪ Community Transformation Grants (CTG) program established with CDC funding toprevent chronic diseases

▪ Reducing Avoidable Readmissions Effectively (RARE) program established

▪ National Quality Forum endorses MN’s Total Cost Index (TCI), the basis of efforts todetermine Total Cost of Care

▪ 2012 Roadmap to a Healthier Minnesota publishes recommendations to chart the nexthorizon of state-level system reform

▪ 32 CMS Pioneer ACOs are announced, including 3 in Minnesota

▪ SIM testing grant awarded▪ MNsure launched, allowing Minnesotans to purchase individual insurance on the

exchange

2014▪ MNCM launched and completed pilot program for Total Cost Index (TCI) with all major

commercial health plans in the state and begins data collection to publicly report on themeasure, possibly by the end of 2014

44

2. Acronyms

ACA AccordableCareAct

ACO AccountableCareOrganization

ADHD AttentionDeficitHyperactivityDisorder

AHA American Hospital Association

APCD AllPayerClaimsDatabase

BPCI BundledPaymentsforCareImprovement

CAHPS Consumer Assessment of Healthcare ProvidersandSystems

CDC CentersforDiseaseControlandPrevention

CMMI CentersforMedicareandMedicaidInnovation

CMS CentersforMedicareandMedicaidServices

DRG DiagnosisRelatedGroup

EMR ElectronicMedicalRecord

EPO ExclusiveProviderOrganization

FPL FederalPovertyLevel

GDP GrossDomesticProduct

GDR GenericDispensingRate

HCH Health Care Homes

HCI3 Heatlth Care Incentives Improvement Institute

HIT HealthInformationTechnology

HMO HealthMaintenanceOrganization

HPSA HealthProfessionalShortageAreas

ICSI Institute for Clinical Systems Improvement

IDS IntegratedDeliverySystem

MBP MinnesotaBusinessPartnership

MCHEC MinnesotaCenterforHealthcareElectronicCommerce

MDH MinnesotaDepartmentofHealth

MDHI MinnesotaHealthDataInstitute

MHCCRS MinnesotaHealthCareClaimsReportingSystem

MNCM MinnesotaCommunityMeasurement

NCQA National Committee for Quality Assurance

NQF National Quality Forum

PCMH Patient-CenteredMedicalHome

PCP Primary Care Physician

SCHSAC StateCommunityHealthServicesAdvisoryCommittees

SHIP State-wideHealthImprovementProgram

SIM StateInnovationModel

SQRMS StatewideQualityReportingMeasurementSystem

TCOC Total Cost of Care

TCRRV TotalCareRelativeResourceValue

TPA ThirdPartyAdministrator

45

3. Performance scorecard measure definitions

Measures are listed in order of appearance on the scorecard.

Category 1: Coverage and access

1.1 Health care coverage

Payer mix: percent uninsured:Percentofthepopulationthatdoesnothavehealthinsurance,basedonHealthLeadersInterstudy’sanalysisofdatafromtheU.S.CensusBureau“SmallAreaHealthInsuranceEstimate(SAHIE)”foruninsuredfiguresforthepopulationunder65yearsofage.Theestimateforpersons65andoverisanationalestimateof2%,basedoncurrentU.S.CensusBureaustudies.

Percent with inadequate health coverage: Percentoftheunder-65populationthatbelongstoahouseholdspending10%ormoreofincomeonmedicalcare(excludingpremiums)or5%ormoreif incomeisunder200%FPL,basedondatafromtheCommonwealthFundHealthInsurancesurvey,a nationallyrepresentativetelephonestudyofpeopleage10andoverinthecontinentalU.S.

Payer mix: percent commercial insured:Percentofthepopulationcoveredundercommercialhealthinsuranceplans(individual,group,federalemployeehealthbenefitplan[FEHBP],consumer-drivenhealthplan[CDHP],state/localemployeeplan,BlueCardHOME,studenthealthandEPO)basedoncommercialmedicalenrollmentfromtheHealthLeaders-Interstudy(HLI)NationalMedicalandPharmacyCensusandpopulationdatafromtheU.S.CensusBureauandCensusBureau’sPopulationEstimatesProgram.

Payer mix: percent Medicaid beneficiaries: PercentoftotalpopulationreceivingMedicaidbenefits(includingdualeligibles)basedondataobtainedbyHLIdirectlyfromindividualstateinsuranceagenciesandpopulationdatafromtheU.S.CensusBureauandCensusBureau’sPopulationEstimatesProgram.

Payer mix: percent Medicare beneficiaries:PercentoftotalpopulationreceivingMedicarebenefitsbasedondataobtainedbyHLIfromCMSandpopulationdatafromtheU.S.CensusBureauandCensusBureau’sPopulationEstimatesProgram.

High-deductible health plans: percentage of commercial enrollment covered by HSA/HDHP: Percentofthecommerciallyinsuredpopulationenrolledinhealthsavingsaccountsorhigh-deductiblehealth plans.

Percent Medicaid eligible enrolled in Medicaid: PercentofMedicaidbeneficiariesthatareenrolledinMCO-managedMedicaid.

Percent Medicare eligible enrolled in managed Medicare (Medicare Advantage): Percent of MedicarebeneficiariesenrolledinMedicareAdvantage.

Category 1: Coverage and access


Number of individuals per American College of Surgeons (ACS)-verified trauma center (in thousands):StatepopulationdividedbythenumberofACS-verifiedtraumacenters,asreportedbythe ACS website.

Number of individuals per primary care physician: Statepopulation,asreportedbytheU.S.CensusBureau,dividedbythenumberofprimarycarephysicians(internalmedicine,familymedicine/generalpractice,obstetrics/gynecology,pediatrics),asreportedbytheKaiserFamilyFoundation’sanalysisofStateLicensingInformationdata.

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Percent of population in Primary Care Health Professional Shortage Areas (HPSAs): >3,500 individuals per PCP: Percentofpopulationresidinginareasinwhichtherearemorethan3,500individualsperprimarycarephysician,asmeasuredbytheU.S.DepartmentofHealthandHumanServicesHealthResourcesandServicesAdministration.

Percent of PCP needs met (Current number of physicians/Number of physicians needed to eliminate the HPSA status):CurrentnumberofprimarycarephysiciansdividedbythenumberofprimarycarephysiciansneededtoeliminatetheHPSAstatusthatindicatestherearemorethan3,500individualsperprimarycarephysician,asmeasuredbytheU.S.DepartmentofHealthandHumanServicesHealthResourcesandServicesAdministration.

Number of individuals per specialist: Statepopulationdividedbythenumberofspecialistphysicians,asreportedbytheKaiserFamilyFoundation’sanalysisofStateLicensingInformationdata.

Number of individuals per hospital (in thousands): Statepopulationdividedbythenumberofhospitals,asreportedbytheAmericanHospitalAssociation(AHA).

Occupancy rates in community hospitals: Averageoccupancyrate((Inpatientdaysofcare/Beddaysavailable)x100)forcommunityhospitals,asreportedbytheAHA.Communityhospitalsaredefinedasallnonfederal,short-termgeneral,andotherspecialhospitals.

Percent of hospitals with positive net income:PercentofhospitalsinthestatethatreportedanexcessofrevenueoverexpensesinrespondingtotheAHA’sannualcostsurveyin2012.

Average doctor office wait times (in minutes): Averagetimepatientsspentwaitinginadoctor’sofficebeforebeingseen,asreportedtoVitals,anindependentsurveyorofpatientexperienceforoveramilliondoctors,dentists,andmedicalfacilities.

System integration: percent of physicians employed by hospitals: Number of physicians that responded“Yes”inatelephonesurveyonwhethertheyweredirectlyemployedbyahospitaloremployedbyamedicalgroupthatisownedbyahospital,asreportedbySK&APhysicianDirectoryinMay2013.

Percent of physicians belonging to a medical group: Numberofphysiciansthatresponded“Yes”inatelephonesurveyonwhethertheybelongtoamedicalgroup,asreportedbySK&APhysicianDirectoryinMay2013.

System integration: percent hospitals in a system: PercentofhospitalsthatreportedbeingaffiliatedwithasystemtotheAHAannualhospitalsurveyin2012.AsystemisdefinedbyAHAaseitheramulti-hospitaloradiversifiedsingle-hospitalsystem.Amulti-hospitalsystemistwoormorehospitalsowned,leased,sponsored,orcontract-managedbyacentralorganization.Single,freestandinghospitalsmaybecategorizedasasystembybringingintomembershipthreeormore,andatleast25%,oftheirownedorleasednonhospitalpre-acuteorpost-acutehealthcareorganizations.Systemaffiliationdoesnotprecludenetworkparticipation.

System integration: percent of hospitals in a network: PercentofhospitalsthatreportedbelongingtoanetworktotheAHAannualhospitalsurveyin2012.AnetworkisdefinedbyAHAasagroupofhospitals,physicians,otherproviders,insurers,and/orcommunityagenciesthatworktogethertocoordinateanddeliverabroadspectrumofservicestotheircommunity.Networkparticipationdoesnotprecludesystemaffiliation.

Average number of physicians in a medical group: Averagenumberofphysiciansthatreported“Yes”inatelephonesurveyonwhethertheybelongtoamedicalgroupandreportedbelongingtothesamemedicalgroup,asreportedbySK&APhysicianDirectoryinMay2013.

Medicaid eligibility limits: Eligibilitylevelsarebasedon2014federalpovertylevelsandreflectmodifiedadjustedgrossincome-convertedincomestandardsthatincludeafive-percentagepointofthefederalpovertyleveldisregard.Eligibilitystandardsarebasedonafamilyofthreeforparentsof

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dependentchildrenandonanindividualbasisforotheradults.FiguresarebasedondatafromtheCMSStateMedicaidandCHIPIncomeEligibilityStandardseffectApril1,2014,accessedMay12,2014.

Dual eligible enrollees: duals as a percent of Medicaid enrollment: NumberofdualeligiblesenrolledintheMedicaidprogramdividedbythenumberoftotalMedicaidbeneficiaries,basedonestimatesbytheKaiserCommissiononMedicaidandtheUninsuredandUrbanInstitute’sanalysisof2010datafromtheMedicaidStatisticalInformationSystems(MSIS).

Distribution of Medicaid enrollees by enrollment group: Enrollees by given enrollment group as a percent of total Medicaid beneficiaries. Enrollees:IndividualswhoareenrolledinMedicaidatanytimeduringthefederalfiscalyear.Aged:Includesallpeopleage65andolder.Disabled:Includespeopleunderage65whoarereportedaseligibleduetoadisability.Adults:Generallypeopleage19–64,includingasmallnumberofpeoplewhoareeligiblethroughtheBreastandCervicalCancerPreventionandTreatmentActof2000.Children:Generallypeopleage18andyounger.However,somepeopleage19andoldermaybeclassifiedas“children”dependingonwhytheyqualityfortheprogramandeachstate’spractices.

Category 2: Population health


Air Quality Index: AirQualityIndexisbasedontheEPA’sAirDataAirQualityIndexSummaryReportandrepresentsaratioofthestate’sannualdayswithAirQualityIndex(AQI)lessthan50tonationalaverageannualdayswithAQIlessthan50;valueofgreaterthan1representsastatewithagreaternumberof“Good”dayscomparedwiththenationalaverage.AQIisanindicatorofoverallairquality,becauseittakesintoaccountallofthecriteriaairpollutantsmeasuredwithinageographicarea.

Injury deaths (per 100,000): Totalnumberofdeathsforselectedcauses(per the International Classification of Diseases, Tenth Revision, 2ndEdition,2004codes*U01-*U03,V01-Y36,Y85-Y87,Y89)standardizedtoper100,000population,basedondatafromtheCDCNationalVitalStatistics.

Occupational fatalities (per 100,000 workers): :Totalnumberoffatalitiesfromoccupationalinjuriesper100,000workers,asmeasuredbytheU.S.BureauofLaborStatistics.

Percent of adults reporting excessive drinking: Percentofadultsthatreportedeitherheavydrinking(15ormoredrinksperweekformenor8ormoredrinksperweekforwomen)orbingedrinking(drinking5ormoredrinksonoccasionformenor4ormoredrinksonanoccasionforwomen)ontheCDCBehavioralRiskFactorSurveillanceSystem(BRFSS)survey.

Percent of persons 12 and over with any illicit drug use in the past month: BasedonresponsestotheSubstanceAbuseandMentalHealthServicesAdministration’sNationalSurveyonDrugUse&Health.Informationonillicitdruguseiscollectedforsurveyparticipantsaged12andover.Informationonanyillicitdrugincludesanyuseofinhalants,aswellasnonmedicaluseofprescriptionpsychotherapeuticdrugs.Currentuse(withinthepastmonth)isbasedonthequestion:“Howlonghasitbeensinceyoulastused(drugname)?”

Percent of adults reporting no exercise in the last 30 days: Percentageofadultswhoreport,intheirresponsestothe2012CDCBehavioralRiskFactorSurveillanceSurvey,doingnophysicalactivityorexercise(suchasrunning,calisthenics,golf,gardening,orwalking)otherthantheirregularjobinthelast30days.

Percent of adults reporting consumption of fewer than 5 servings of fruits/vegetables per day: BasedonresponsestotheCDCBehavioralRiskFactorSurveillanceSystem(BRFSS):SixBRFSSquestionsassessfruitandvegetableintakeandaretheonlydietintakequestionsonthecoresurvey:“Thesenextquestionsareaboutthefoodsyouusuallyeatordrink.Pleasetellmehowoftenyoueat

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ordrinkeachone,forexample,twiceaweek,threetimesamonth,andsoforth.Howoftendoyou...”1)“...drinkfruitjuicessuchasorange,grapefruit,ortomato?”2)“Notcountingjuice,howoftendoyoueatfruit?”3)“...eatgreensalad?”4)“...eatpotatoes,notincludingFrenchfries,friedpotatoes,orpotatochips?”5)“...eatcarrots?”6)“Notcountingcarrots,potatoes,orsalad,howmanyservingsofvegetablesdoyouusuallyeat?”Consumptionwasdividedby7forweeklyfrequencies,30formonthlyfrequencies,and365foryearlyfrequenciestocalculatedailyconsumption.Totaldailyconsumptionoffruitwasthesumofresponsestoquestions1–2andvegetablesthesumofresponsestoquestions3–6.Participantswerenotgivenadefinitionofservingsize.

Percent of adults who self-report cigarette smoking: SmokingprevalenceisdefinedbytheCDCBRFSSasthepercentageofadultswhoself-reportsmokingatleast100cigarettesintheirlifetimeandwhoarecurrentlysmoking.

Percent of high school students reporting cigarette use in the last month: SmokingprevalenceisdefinedbytheCDCBRFSSYouthRiskBehaviorSurveyasthepercentageofadolescentsin9th–12thgradeswhoreportsmokingonatleast1dayduringthe30daysbeforethesurvey.

Percent of adults designated as obese: Percentageofadultswhoareobese,withabodymassindex(BMI)of30.0orhigher–basedonresponsestoCDCBRFSS.

Percent of children ages 10-17 designated as obese (BMI > 95th percentile): Percentofchildrenobeseisdefinedasstudentswhowere≥95thpercentileforbodymassindex,basedonsex-andage-specificreferencedatafromthe2000CDCgrowthcharts.

Percent of adults with high blood pressure: PercentageofadultswhorespondedthattheyhavebeentoldbyahealthprofessionalthattheyhavehighbloodpressureinresponsetotheCDCBRFSS.


2.2 Prevalence and incidence

Percent of Medicare beneficiaries with 2 or more chronic conditions: Individualsthathavebeenidentifiedhashavingmultiple(≥2)chronicconditions(fromasetof15specifiedchronicconditions),basedonCMSadministrationdata.

Invasive cancer incidence rate (per 100,000): Figuresarebasedondatacollectedfromselectedstatewideandmetropolitanareacancerregistriesthatmeetthedataqualitycriteriaforallinvasivecancersitescombined,compiledbytheCDC’sU.S.CancerStatisticsWorkingGroup.Figureshavebeenage-adjustedtothe2000U.S.standardpopulation.

Percent of adults who have ever been told they have diabetes/asthma: DatabasedontheCDC’sBRFSS,anongoing,state-based,random-digit-dialedtelephonesurveyofnon-institutionalizedcivilianadultsaged18yearsandolder.

Chlamydia, Gonorrhea, and Syphilis case rates (per 100,000): BasedondatafromtheCDCNationalVitalStatisticsSystemandtheMDHCountytables.

Percent of adults with mental illness: BasedontheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)’sNationalSurveyonDrugUseandHealth’sfindingsfor“AnyMentalIllness”(AMI)amongadultsaged18orolder.AMIisdefinedascurrentlyoratanytimeinthepast12monthshavinghadadiagnosablemental,behavioral,oremotionaldisorder(excludingdevelopmentalandsubstanceusedisorders)ofsufficientdurationtomeetdiagnosticcriteriaspecifiedwithin the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV;AmericanPsychiatricAssociation [APA],1994).

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2.3 Health outcomes

Percent of population that self-reported “poor” or “fair” health: Basedonsamplerespondentsage18andolderwhoself-reportedfairorpoorhealthstatustotheCDCBRFSSquestion:“Wouldyousaythatingeneralyourhealthis–Excellent,Verygood,Good,Fair,orPoor?”Figureswereadjustedforage.

Gallup-Healthways Well-Being Index: TheGallup-HealthwaysIndexisbasedonthesurveyresponsesof500Americansdaily.TheIndexiscalculatedbasedonrespondents’scoringona0–10scaleonquestionitemsacrosssixdomains:LifeEvaluation,EmotionalHealth,WorkEnvironment,PhysicalHealth,HealthyBehavior,BasicAccess.

Stroke/Alzheimer’s disease/Heart disease/Influenza and pneumonia/Homicide/Suicide deaths (per 100,000):BasedondatafromtheCDCNationalVitalStatisticsSystem.Figureswereadjustedforage.

Infant mortality rate (per 1,000 live births): Numberofinfantdeathsper1,000livebirthsbasedonlinkedbirthanddeathrecordsfromtheCDCNationalVitalStatisticsSystem.Infantsaredefinedaschildrenunder1yearofage.

Percent of low-birth-weight live births: Numberofbabiesbornlowbirthweight,definedaslessthan2,500grams,asapercentofalllivebirths,basedonCDCNationalVitalStatisticsSystem.

Perinatal deaths (per 1,000 live births): Numberoffetalandinfantdeathsduringtheperinatalperiod(28weeksofgestationto7daysafterbirth)asapercentofthenumberoflivebirthsplusfetaldeathsofatleast28weeksgestation,basedontheLinkBirth/InfantDeathDataSetbytheCDC’sNationalVitalStatisticsSystem.

Hospital rates of early scheduled delivery: percentofmotherswhoindicatedelectivedeliveryasapercentoftotalmotherswhodeliveredbetween37–39weeksofgestation:BasedonhospitalresponsestotheLeapfrogHospitalSurvey.

Category 3: Health care delivery


CAHPS measures of patient experience: BasedonMinnesota-specificdatacollectedbyMinnesotaCommunityMeasurementandnationaldatapublishedbytheNCQA.Hospital-specificmeasureof“Percentofpatientswhoreported,‘Yes,’theywoulddefinitelyrecommendthehospital”isbasedonHospitalCAHPSPatientSurveyResultsreleasedbyCMSHospitalCompare.

Hospital safety score: percent of hospitals that received a grade of “A”: The Hospital Safety Score uses28nationalperformancemeasuresfromtheLeapfrogHospitalSurvey,theAgencyforHealthcareResearchandQuality,theCentersforDiseaseControlandPrevention,andtheCentersforMedicareandMedicaidServicestoproduceasinglescorerepresentingahospital’soverallperformanceinkeepingpatientssafefrompreventableharmandmedicalerrors.Source: Hospital Safety Score(http://www.hospitalsafetyscore.org/).

Category 3: Health care delivery

3.2 Quality of care

Average of Medicare ACOs’ performance on 5 reported quality-of-care measures: Figuresrepresentstate-levelrawaveragesacrossallMedicareACOsinthestateusingqualityindicatorsreportedbyMedicare.gov:AccountableCareOrganization(ACO)QualityReporting (http://www.medicare.gov/physiciancompare/aco/search.html).

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Acute/inpatient care quality of care indicators (Average number of minutes patients spend in the ED before they were admitted, Percent outpatients having surgery who got an antibiotic at the right time, Percent of HF patients given ACE inhibitor or ARB for left ventricular systolic dysfunction):BasedonhospitalqualityinformationreleasedbyCMSHospitalCompare (http://www.medicare.gov/hospitalcompare/search.html).

Management of chronic conditions (Percent of diabetes patients meeting target levels for modifiable risk factors, Percent of depression patients who have reached remission, Percent of patients 18–85 who had a diagnosis of hypertension and whose blood pressure was adequately controlled): BasedonMinnesota-specificdatapublishedbyMNCMintheirannualHealthCareQualityReport (http://mncm.org/reports-and-websites/reports-and-data/).

Screening and immunization (Percent of women ages 24–64 who were screened for cervical cancer, Percent of patients ages 51–75 who were up to date with appropriate colorectal cancer screening exams, Percent of women 40–69 who had a mammogram to screen for breast cancer): BasedonMinnesota-specificdatapublishedbyMNCMintheirannualHealthCareQualityReport (http://mncm.org/reports-and-websites/reports-and-data/).

Childhood immunization status: percent of 2-year-old children who had CDC-recommended 4:3:1:3*3:1:4 series of immunizations:BasedondatafromNationalImmunizationSurvey(NIS).Estimatedvaccinationcoverageamongchildren19–35monthsforcombinedvaccinationseriesknownas4:3:1:3*3:1:4series,referredtoasroutine,thatincludes≥4dosesofDTaP,≥3dosesofpoliovirusvaccine,≥1dosesofmeaslesvaccine,fullseriesofHib(3or4doses,dependingonproduct),≥3dosesofHepB,≥1dosesofvaricellavaccine,and≥4dosesofPCV.

Medicare Part C Star Rating: StateaveragesrepresenttheaverageofhealthinsuranceproductPartCStarRatingswithinthestateweightedbyenrollmentbyproduct.BasedondatafromCMS.gov:PartCandDPerformanceData.

Percentage of adults reporting improved functioning from the public mental health system in the past 6 months: BasedontheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)’sNationalSurveyonDrugUseandHealth.

Category 4: Health care cost


Per capita personal health care expenditures by state of residence:BasedonCMSNationalHealthExpendituresHealthAccountsbystateofresidence.NHEpresentsaggregateandpercapitaestimatesofpersonalhealthcarespendingbytypeofestablishmentdeliveringcare(hospitals,physiciansandclinics,nursinghomes,etc.)andformedicalproducts(prescriptiondrugs,over-the-countermedicines,andsundriesanddurablemedicalproductssuchaseyeglassesandhearingaids),purchasedinretailoutlets.

Per capita hospital expense:Includesalloperatingandnon-operatingexpensesforregisteredUScommunityhospitals,definedasnon-federal,short-term,general,andotherspecialhospitalswhosefacilitiesandservicesareavailabletothepublic,adjustedforstatepopulation,asreportedtotheAmericanHospitalAssociation’sAnnualSurvey.Itisimportanttonotethatthesefiguresareonlyanestimateofexpensesincurredbythehospitaltoprovideadayofinpatientcareandarenotasubstituteforeitheractualchargesorreimbursementforcareprovided.

Total family premiums per enrolled employee at private sector establishments (average in dollars), Total premiums for private sector employees enrolled in single coverage (average in dollars):BasedontheAgencyforHealthcareResearchandQuality’sMedicalExpenditurePanelSurvey’sInsuranceComponent (http://meps.ahrq.gov/survey_comp/ic_technical_notes.shtml).

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Total family premiums per enrolled employee at private sector establishments (average in dollars) as a percent of median household income: MEPSsurveyresponsesfor“TotalFamilyPremiumperEnrolledEmployees”dividedbystatemedianhouseholdincome(asreportedbyAmericanCommunitySurvey).

Total medical costs per member per month for commercial health plans (state average in dollars):BasedonNAICfilingsaggregatedbySNLFinancials.Figuresreported“HealthProvisionsPaid”by“Membermonths”asreportedbycommercialhealthinsurancecompanies.

Total Medicare reimbursements per enrollee: Medicarereimbursementsperenrollee(PartsAandB),adjustedforprice,age,sex,andrace.

Part D spending per Medicare beneficiary:Numerator:PartDeventrecordswereusedtocalculateindividual-leveltotalPartDprescriptionspending.Denominator:Prescriptiondrugutilizationandspendingratesuseda40%Medicarerandom-sampledenominatorfileforeachyearfrom2006–2010.Forthe2010PartDenrollmentcohort,patientswereincludediftheywere(1)age65orolderasof1/1/2010,(2)aliveandcontinuouslyenrolledinastand-aloneMedicarePartDplanforall12monthsof2010,and(3)notenrolledinhospiceoramanagedMedicareplan(MedicareAdvantage)atanytimeduring2010.

CMS Medicare hospital spending per patient (indexed to Medicare spending per patient on hospital care nationally):The“Medicarehospitalspendingperpatient(MedicareSpendingperBeneficiary)”measureshowswhetherMedicarespendsmore,less,oraboutthesameperMedicarepatienttreatedinaspecifichospital,comparedwithhowmuchMedicarespendsperpatientnationally.ThismeasureincludesanyMedicarePartAandPartBpaymentsmadeforservicesprovidedtoapatientduringthe3dayspriortothehospitalstay,duringthestay,andduringthe30daysafterdischargefromthehospital.Thedatadisplayedherearetheaveragemeasuresforeachstate.

Medicare spending per decedent during the last 2 years of life: IncludesspendingfromMedPAR,HomeHealthAgency,HospiceandDME,thePartBfile,andtheOutpatientfile;ratesareadjustedforage,sex,race,primarychroniccondition,andthepresenceofmorethanonechronicconditionusingordinaryleast-squaresregression.

Medicaid per enrollee payments:DividedtotalpaymentbyBasisofEligibility(BOE)bytotalenrollmentforBOEcategorydatafromtheMedicaidStatisticalInformationSystems.Adjustedtotalpopulationperenrolleespendfiguretoreflecttheweightedaveragespendbyeligibilitycategory,calculatedasaverageexpenditureperbeneficiaryforeachBOEcategory.

Dual eligible enrollees: Duals’ share of Medicaid spending: May2010MAState/CountyPenetrationFileandKaiserCommissiononMedicaidandtheUninsuredandUrbanInstituteestimatesbasedondatafromFY2010MSIS.MSISdatafrom2009wereusedforColorado,Idaho,Missouri,NorthCarolina,andWestVirginia,because2010datawereunavailable.

Medicaid expenditure as a percent of total state expenditures, Change in Medicaid expenditure as a percent of change in state GDP: TheNationalAssociationofStateBudgetOffice’sestimates.


4.2 Utilization

Hospital admissions per 1,000 residents, Hospital emergency room visits per 1,000 residents: FiguresbasedoncommunityhospitalresponsestotheAHAAnnualSurvey.Communityhospitalsare

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allnon-federal,short-termgeneral,andspecialtyhospitalswhosefacilitiesandservicesareavailabletothepublicandrepresent85%ofallhospitals.

Average length of stay:Averagelengthoftimebetweenapatient’sadmissiondateanddateofdischarge,basedonAvalereHealthanalysisofAmericanHospitalAssociationAnnualSurveydataforcommunity hospitals.

Commercial: Acutehospitaladmissionsper1,000members:Numberofhospitalsadmissionsper1,000healthplanenrollments,basedoncommercialclaimsdatamadeavailablebyTruvenHealthAnalytics.

All-cause 30-day Medicare readmission rate:The30-daydeath(mortality)measuresareestimatesofdeathsfromanycausewithin30daysofahospitaladmission,forpatientshospitalizedwithoneofseveralprimarydiagnoses.Deathscanbecountedinthemeasuresregardlessofwhetherthepatientdieswhilestillinthehospitalorafterdischarge.CMSchosetomeasuredeathwithin30daysinsteadofinpatientdeathstouseamoreconsistentmeasurementtimewindowbecauselengthofhospitalstayvariesacrosspatientsandhospitals.Also,mortalityoverlongertimeperiods(suchas90days)mayhavelesstodowiththecarereceivedinthehospitalandmoretodowithothercomplicatingillnesses,patients’ownbehavior,orcareprovidedtopatientsafterhospitaldischarge.

Percent outpatients with low back pain who had MRI without trying other treatments, Percent outpatients with low brain CT scans who got a sinus CT scan at the same time, Percent outpatient CT scans of the chest that were combination (double) scans:OutpatientimagingefficiencymeasuresapplyonlytoMedicarebeneficiariesenrolledinfee-for-serviceMedicarewhoweretreatedasoutpatientsinhospitalfacilitiesreimbursedthroughtheOutpatientProspectivePaymentSystem(OPPS).TheydonotincludeMedicaremanagedcarepatients,non-Medicarepatients,orpatientswhowereadmittedtothehospitalasinpatients.CMScalculatesimagingefficiencymeasuresusingdatafromclaimsthathospitalsandphysicianssubmitforMedicarebeneficiariesenrolledinOriginalMedicare.ThedataarecalculatedonlyforhospitalspaidthroughtheOutpatientProspectivePaymentSystem(OPPS).Outpatientimagingefficiencymeasuresarenotriskadjusted.However,thesemeasuresdonotincludecaseswherethereareclearmedicalreasonsforperformingthetests.

Ratio of specialist visits: PCP visits:Ratioofoffice-basedvisitstomedicalspecialistsandprimarycarephysicians;analysisisbasedon2010–2012TruvenCommercialDataset.

Discharges for Ambulatory Care-Sensitive Conditions per 1,000 Medicare enrollees: 100%ofMedicareenrolleesage65–99withfullPartAentitlementandnoHMOenrollmentduringthemeasurementperiod;ratesareadjustedforage,sex,andraceusingtheindirectmethod,withtheU.S.Medicarepopulationasthestandard.

Percent of Medicare decedents seeing 10 or more different physicians during the last 6 months of life: Thenumberofphysiciansseeninthelast6monthsoflifeiscomputedbasedontheUniqueProviderIdentificationNumber(UPIN)onthePartBclaim;ratesareadjustedforage,sex,race,primarychroniccondition,andthepresenceofmorethanonechronicconditionusingordinaryleast-squaresregression.

Medicare Generic Dispensing Rate (GDR):PrescriptionsFilledwithGenericProductswascalculatedasthedifferencebetweentotal30-DayPrescriptionsFilledand30-DayPrescriptionsFilledwithBrand-NameProducts,asreportedbytheDartmouthAtlasdataonMedicarePrescriptionDrugUtilization.

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4.3 Unit cost

Commercial reimbursement per CPT: Index of payment for 100 most-common physician office-based procedures:Compositeindexcomputedbasedontop100most-commonCPTprocedurecodesrenderedinthedoctors’officesin2012;analysisisbasedon2010–2012TruvenCommercialDataset

Commercial reimbursement per DRG: Index of payment for 100 most-common DRG discharges:Compositeindexcomputedbasedontop100mostcommonDRGdischargesin2012;analysisisbasedon2010–2012TruvenCommercialDataset.

Cost per acute inpatient admission:Costperacuteinpatientadmissionisadjustedforageandgender;analysisisbasedon2010–2012TruvenCommercialDataset.

Medicare Inpatient Prospective Payment System (IPPS) Geographic Adjustment Factor (GAF) (average of urban area-level weighted by Medicare discharges):Linkedhospital-levelMedicaredischargeinformationtoMSA-specificGAFtoconstructweightedaverageatthestatelevel.

Weighted average Medicare reimbursement per DRG:Compositeindexcomputedbasedonthetop100most-commonDRGdischarges,updatedtoinclude2012figuresreleasedbyCMSonJune2,2014.

Category 5: Status of health care reform efforts

5.1 Health Information Technology

Percentage of office-based physicians using EMR/EHR:PercentofsurveyedphysiciansthatreportedhavingaBasicEMRsysteminplaceontheDCD’sNationalAmbulatoryMedicalCareSurvey,ElectronicHealthRecordsSurvey.ABasicEMRsystemisdefinedasasystemthathasallofthefollowingfunctionalities:patienthistoryanddemographics,patientproblemlists,physicianclinicalnotes,comprehensivelistofpatients’medicationsandallergies,computerizedordersforprescriptions,andabilitytoviewlaboratoryandimagingresultselectronically.

Percent of physicians routing prescriptions electronically, Percent of community pharmacies e-prescribing-activated:Basedonatotalcountof522,000office-basedphysiciansintheU.S.perSK&Adata.Surescripts’countofactive-physicianresponsesrepresentsthoseambulatory-carephysicianswhousedelectronicprescriptionroutingwithinthelast30daysof2013.Forthecalculationofactiveoffice-basedphysiciansin2013,Surescriptsmadea15%adjustmenttoremoveacutephysiciansthataree-prescribing.



Percent of primary care practices that are Patient-Centered Medical Home (PCMH)-certified:MNfigureisbasedonMNdefinitionofPCMH;nationalfigureisbasedon%ofPCMH-certifiedasNCQAPCMHLevels1–3.

Percent Medicare FFS beneficiaries attributed to a Medicare ACO:Dividedtotalcountoffee-for-servicebeneficiariesattributedtoMedicareACOsbytotalMedicareFFSbeneficiariesinthestate,basedondatafromCMSMedicareAdministrativefiles.

Bundled Payments for Care Improvement (BPCI):percentofeligibleprovidersparticipatinginprogram:DividedtotalcountofBPCIparticipatingprovidersbytotalcountofprovidersthatare

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eligiblefortheprogram(fromMedicareProviderofServiceFiles:Inpatienthospitals+InpatientRehabfacilities+Homehealthagencies+Long-termcarehospitals+SkilledNursingFacilities).

Number of commercial and Medicare ACOs:TotalcountofcommercialandMedicareACOs,asidentifiedthroughpresssearchesbyHealthQuestPublishers2014ACODirectory,currentasofJanuary 2014.

Number of Medicare ACOs:State-levelcountsofallPioneerandMedicareSharedSavingsProgramACOs,publishedbytheMedicareACOProgramNewsandAnnouncementswebpage.CurrentasofApril 2014.


5.3 Medicaid expansion

Percent change Pre-Open Enrollment (Monthly Average) to July 2014:ThepercentchangeinTotalMedicaidandCHIPEnrollment,fromthePre-OpenEnrollmentMonthlyAverageMedicaidandCHIPEnrollment(July–Sept2013)toJuly2014amongstatesreportingdataforbothperiods.Anegativepercentagechangemaybeduetoanumberoffactors,includingthepreliminarynatureofthemonthlydata(asdescribedabove)ascomparedwiththefinalizednatureofthebaselinedata.Changesinenrollmentlevelsaredrivenbythenumberofnewlyenrolledindividualsaswellasbythenumberofindividualswhosecoveragehasterminated.FiguresarebasedondataonMedicaid&CHIPMonthlyApplications,EligibilityDeterminations,andEnrollmentReportsreleasedbyCMSasofSeptember22,2014.

Percentage drop in uninsured (2010-2014):Basedonrespondents’self-reportsofhealthinsurancestatuswhenaskedthequestions,“Doyouhavehealthinsurancecoverage?”ontheGallup-Healthwaysmid-yearWell-BeingIndexsurveysfor2010and2014.


5.4 State health care exchanges

Latest marketplace QHP selection total as percent of non-elderly (0-64), non-Medicaid-eligible uninsured population: Total health insurance marketplace enrollment as of April 2014 as a percent ofnon-elderly,non-Medicaideligible,uninsuredpopulation,basedondatacollectedbytheMcKinseyCenter for U.S. Reform.

Health insurance marketplace enrollment as a share of potential marketplace population: This metricreflectsthenumberof1)Individualswhohaveselectedamarketplaceplanasapercentofthe2)Estimatednumberofpotentialmarketplaceenrollees.1)IndividualsWhoHaveSelectedaMarketplacePlan:RepresentthetotalnumberofindividualswhohavebeendeterminedeligibletoenrollinaplanthroughtheMarketplaceandwhohaveselectedaplan(withorwithoutthefirstpremiumpaymenthavingbeenreceiveddirectlybytheMarketplaceortheissuer).2)EstimatedNumberofPotentialMarketplaceEnrollees:Includeslegallyresidingindividualswhoareuninsuredorpurchasenon-groupcoverage,haveincomesaboveMedicaid/CHIPeligibilitylevels,andwhodonothaveaccesstoemployer-sponsoredcoverage.TheestimateexcludesuninsuredindividualswithincomesbelowthefederalpovertylevelwholiveinstatesthatelectednottoexpandtheMedicaidprogram;theseindividualsarenoteligibleforfinancialassistanceandareunlikelytohavetheresourcestopurchasecoverageintheMarketplace.OfficeoftheAssistantSecretaryforPlanningandEvaluation(ASPE),DepartmentofHealthandHumanServices(HHS);May1,2014andState-by-StateEstimatesoftheNumberofPeopleEligibleforPremiumTaxCreditsUndertheAffordableCareAct,KaiserFamilyFoundation,November5,2013.

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Number of insurers in the individual health insurance marketplace: Count of private insurance companiesthatofferindividualhealthinsuranceexchangeproducts,basedondatacollectedbytheMcKinseyCenterforU.S.HealthReformfromexchangewebsites.

Ratio of unique carriers on exchange: carriers in the individual market in 2012: Count of private insurancecompaniesthatofferindividualhealthinsuranceexchangeproductscomparedwiththenumberofhealthinsurancecompaniesofferingindividualhealthinsuranceproductsin2012,basedondatacollectedbytheMcKinseyCenterforU.S.HealthReformfromexchangewebsitesand2012NAICfilings.

Product design: HMO and EPO products as % of all plans on the exchange: Count of Health MaintenanceOrganizationandExclusiveProviderOrganizationsasapercentofallplansofferedonthestatehealthinsuranceexchange,basedondatacollectedbytheMcKinseyCenterforU.S.HealthReformfromexchangewebsites.

Network design: Products with narrow networks as % of all plans on the exchange: Narrow networks aredefinedashaving30–69%ofthe20largesthospitalsnotparticipatingintheinsuranceproduct’sprovidernetwork.“Ultra-narrow”networksaredefinedashavingatleast70%ofthe20largesthospitalsnotparticipating.Basedonhospitalnetworkdatacompiledfrom2014individualexchangemarketproductsanalyzedbytheMcKinseyCenterforU.S.HealthReform.

Minimum price premium for a single 27-year old as % of average state income (Catastrophic, Bronze, Silver, Gold, Platinum):Thepremiumfortheleastexpensivehealthplanofferedbymetallictier,basedondatacollectedbytheMcKinseyCenterforU.S.HealthReformfromexchangewebsites,asapercentofaveragestateincome,basedondatafromtheU.S.CensusBureau’sAmericanCommunity Survey.

2014 monthly premiums for a single 40-year old at 250% of FPL in a major city (Benchmark plan, Second-lowest-cost Silver plan after subsidies, Lowest-cost Bronze Plan before subsidies, Lowest-cost Bronze Plan after subsidies):Premiumdataforstate-runexchangeswerecollectedfromhealthinsurerratefilingssubmittedtostateregulators,andfromstateexchangewebsites.PremiumdataforfederallyfacilitatedandpartnershipexchangesareavailablefromtheDepartmentofHealthandHumanServices.ThesedatawerelastupdatedonOctober22,2013.

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Enrollment by metal tier (Catastrophic, Bronze, Silver, Gold, Platinum): DatarepresentscumulativeMarketplaceenrollment-relatedactivityforOctober1,2013toApril19,2014.Foreachmetric,thedatarepresenttheTotalNumberofIndividualsDeterminedEligibletoEnrollinaPlanThroughtheMarketplacewhohaveselectedaplan(withorwithoutthefirstpremiumpaymenthavingbeenreceiveddirectlybytheMarketplaceortheissuer)duringthereferenceperiod,excludingplanselectionswithunknowndataforagivenmetric.SpecialEnrollmentPeriod(SEP)activityincludesplanselectionsthatweremadebetweenApril1,2014,andApril19,2014,bythosewhoqualifiedforanSEPbecausetheywere“inline”onMarch31,2014,aswellasthosewhoexperiencedaqualifyinglifeeventoracomplexsituationrelatedtoapplyingforcoverageintheMarketplace.

4. Calculation of state rank

Stateranksarecalculatedatthecategorylevelandoverall,acrossthefivecategories.Ranksaregeneratedforall50statesandtheDistrictofColumbia.Categoryranksarecalculatedbytakingtheaveragestaterankforeachstateacrossallnormativemetricswithinthecategory.Statesarethenforcerankedfrom1-51basedontheiraverage.Theoverallstaterankisgeneratedbyfirsttakingtheaverageofthestateranksforeachstateforeachcategory(step1,above),andthenforcerankingstatesfrom1-51.Theaverageistakenbetweencategoriesratherthanacrossallmetricsinthescorecardtogiveeachcategoryequalweighting.Thisisnecessarybecausethereissignificantvariationinthenumberofnormativemetricsineachcategory.

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CITATIONS

1. 2013 Annual Report: A Call to Action for Individuals and Their Communities.America’sHealthRankings:UnitedHealthFoundation,2013.

2. Forexample,MinnesotaplacedfirstinthecountryintheCommonwealthFund’soverallrankingofstatehealthsystemsin2014.Radleyetal.,Scorecard on State Health System Performance, 2014, TheCommonwealthFund,April30,2014.

3. ThesamereportrankedtheMayoClinicfirstinthecountryonhalfofthe16medicalspecialties evaluated.“U.S.NewsBestHospitals2014–15,”U.S. News & World Report, July 15, 2014,(http://health.usnews.com/best-hospitals).

4. “MedicareAccountableCareOrganization(ACO)QualityReporting,”CentersforMedicareandMedicaidServices(http://www.medicare.gov/physiciancompare/aco/search.html).

5. “NewReport:Minnesotais38thMostObeseStateintheNation,”TrustforAmerica’sHealth,July 7,2011.

6. StateInnovationModelGrantApplicationMaterials:ProjectNarrative,HealthReformMinnesota,September2012(http://mn.gov/health-reform/SIM/).

7. The Health of Minnesota: 2012 Statewide Health Assessment,MinnesotaDepartmentofHealth,April 2012.

8. NationalHealthExpenditureData:HealthExpendituresbyStateofResidence,CentersforMedicareandMedicaidServices,1991–2009;Minnesota Health Care Spending and Projects, 2012,MinnesotaDepartmentofHealth,June2014.

9. “Minnesota’sAllPayer’sClaimsDatabase(APCD),”MinnesotaDepartmentofHealth (http://www.health.state.mn.us/healthreform/allpayer/index.html).

10. “StatesGettingaJumpStartonHealthReform’sMedicaidExpansion,”KaiserFamilyFoundation,April 2, 2012.

11. “StateMarketplaceProfiles:Minnesota,”KaiserFamilyFoundation,November12,2013.

12. Theseinclude:CMSPioneerandMedicareSharedSavingsACOprograms,MedicareMulti-payerAdvancedPrimaryPracticedemonstration,BundledPaymentsforCareImprovement(BPCI),CMSDemonstrationtoIntegrateCareforDualEligibles,StrongStartinitiative,andtheStateInnovationModel(SIM)testinggrant;see“WhereInnovationisHappening:Minnesota,”CentersforMedicareandMedicaidServices:InnovationCenter(http://innovation.cms.gov/initiatives/map/index.html).

13.“TopEmployersStatewide,”MinnesotaDepartmentofEmploymentandEconomicDevelopmentanalysisofdatafromtheMinneapolis-St. Paul Business Journal, 2011.

14. “MinnesotaHealthCareIndustryAssessment,”MinnesotaDepartmentofEmploymentandEconomicDevelopmentanalysisofdatafromtheLaborMarketInformationOffice,February2011.

15. Normativemeasuresarethoseforwhichitispossibletoagreeuponbetterandworseperformance,forexample,thepercentageofthepopulationthatisuninsured.Descriptivemeasuresconveyimportantinformation,butarenotsubjecttonormativeinterpretationinthesameway,forexample,thepercentageofthepopulationthatiscoveredthoughprivateinsurance.Ofthe154totalmeasuresincludedinthescorecard,82havebeenclassifiedasnormativeandareusedtorankMinnesotaagainstotherstatesandthenationalaveragetoprovideasenseofrelativeperformance.

16.HealthLeaders-Interstudy’sanalysisofdatafromtheU.S.CensusBureau’s“SmallAreaHealthInsuranceEstimates(SAHIE),”January2014.

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17. Underinsuredisdefinedasinsuredinhouseholdthatspent10%ormoreofincomeonmedicalcare(excludingpremiums)or5%ormoreofincomeunder200%FPL;seeSchoenet al, America’s Uninsured: A State-by State Look at Health Insurance Affordability Prior to the New Coverage Expansions,TheCommonwealthFund,March2014.

18.“UnemploymentRatesforStates—LocalAreaUnemploymentStatistics,”U.S.BureauofLaborStatistics,July2014(http://www.bls.gov/web/laus/laumstrk.htm).

19.HealthLeaders-Interstudy’sanalysisofdatafromtheCentersforMedicareandMedicaid(CMS)andindividualstateinsuranceagencies,January2014.

20. Analysisof2012dataintheMedicaidBenefitsDatabasemaintainedbytheKaiserCommissiononMedicaidandtheUninsuredshowsthatMinnesotaofferedabove-averagebenefitlevelsfornearlyallofthe43differentindividualmedicalservicestracked;see“Medicaid&CHIPIndicators—MedicaidBenefits,”KaiserFamilyFoundation:KaiserStateHealthFacts,2012(http://kff.org/state-category/medicaid-chip/medicaid-benefits/).

21. BasedondatafromtheU.S.CensusBureauandtheKaiserFamilyFoundation’sanalysisofdatafromStateLicensingDepartments;see“PrimaryCarePhysiciansbyField,”KaiserFamilyFoundation,November2012(http://kff.org/other/state-indicator/primary-care-physicians-by-field/).

22. “FindShortageAreas:HPSAbyState&County,”U.S.DepartmentofHealthandHumanServices:HealthResourcesandServicesAdministration(HRSA),April2014(http://hpsafind.hrsa.gov/).

23.Centers for Disease Control and Prevention (CDC): Behavioral Risk Factor Surveillance System Survey Data,Atlanta,Georgia:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,2009–2012.

24. TheGallup-HealthwaysIndexisbasedonthesurveyresponsesof500Americansdaily.TheIndexiscalculatedbasedonrespondentsscoringona0–10scaleonquestionitemsacrosssixdomains:LifeEvaluation,EmotionalHealth,WorkEnvironment,PhysicalHealth,HealthyBehavior,BasicAccess;see“Gallup-HealthwaysSolutions,”Healthways(http://www.healthways.com/solution/default.aspx?id=1125).

25. Centers for Disease Control and Prevention (CDC): Behavioral Risk Factor Surveillance System Survey Data,Atlanta,Georgia:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,2009–2012.

26.National Vital StatisticsSystem,CentersforDiseaseControlandPrevention,NationalCenterforHealthStatistics[accessedJune2014].

27. Centers for Disease Control and Prevention (CDC): Behavioral Risk Factor Surveillance System Survey Data,Atlanta,Georgia:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,2009–2012.

28.Medicare.gov:AccountableCareOrganization(ACO)QualityReporting(http://www.medicare.gov/physiciancompare/aco/search.html).

29.StateaveragesrepresenttheaverageofhealthinsuranceproductPartCStarRatingswithinthestateweightedbyenrollmentbyproduct.BasedondatafromCMS.gov:PartCandDPerformanceData.

30.“MedicareAccountableCareOrganization(ACO)QualityReporting,”CentersforMedicareandMedicaidServices(http://www.medicare.gov/physiciancompare/aco/search.html).

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31.TheHospitalSafetyScoreuses28nationalperformancemeasuresfromtheLeapfrogHospitalSurvey,theAgencyforHealthcareResearchandQuality,theCentersforDiseaseControlandPrevention,andtheCentersforMedicareandMedicaidServicestoproduceasinglescorerepresentingahospital’soverallperformanceinkeepingpatientssafefrompreventableharmandmedicalerrors;see“HospitalSafetyScore:HowSafeisYourLocalHospital,”HospitalSafetyScore(http://www.hospitalsafetyscore.org/).

32.TheNationalImmunizationSurvey(NIS)estimatedvaccinationcoverageamongchildren19–35 monthsforthecombinedvaccinationseriesknownas4:3:1:3*3:1:4series,referredtoasroutine,thatincludes≥4dosesofDTaP,≥3dosesofpoliovirusvaccine,≥1dosesofmeaslesvaccine,fullseriesofHib(3or4doses,dependingonproduct),≥3dosesofHepB,≥1dosesofvaricellavaccine,and≥4dosesofPCV.

33.NationalHealthExpenditureData:HealthExpendituresbyStateofResidence,CentersforMedicareandMedicaidServices,1991–2009;Minnesota Health Care Spending and Projects, 2012, MinnesotaDepartmentofHealth,June2014.

34.“MedicareReimbursementsperEnrollee,”The Dartmouth Atlas of Healthcare,(http://www.dartmouthatlas.org/data/map.aspx?ind=123);“MedicaidStatisticalInformationSystem(MSIS)StateSummaryDatamart,”CentersforMedicareandMedicaidServices(http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html).Seethetechnicalappendixforexactmethodologyforeachmeasure.

35.“MedicalExpenditurePanelSurvey–InsuranceComponent,”AgencyforHealthcareResearchandQuality(http://meps.ahrq.gov/mepsweb/data_stats/quick_tables.jsp).

36.Munsonetal,The Dartmouth Atlas of Medicare Prescription Drug Use,TheDartmouthInstituteforHealthPolicy&ClinicalPractice,October15,2013.

37.BasedonCommercialclaimsdataonthevolumeofoffice-basedvisitstospecialistsandprimarycarephysicians,madeavailablebyTruvenAnalytics.

38.WeightedaverageMedicarereimbursementbystateiscalculatedusingMedicareclaimsdataforthetop100most-commonDRGchargesin2012.

39.Compositeindexcomputedforthetop100mostcommonCPTprocedurecodesrenderedinthedoctor’sofficein2012,basedoncommercialclaimsdatamadeavailablebyTruvenAnalytics.

40. TheHealthCareIncentivesImprovement(HCI3)andtheCatalystforPaymentReformco-publishedastatereportcardontransparencyofphysicianqualityinformationinDecember2013thatrankedMinnesotafirstinthenationonitsprogressinsystematicallycollecting,reporting,andmonitoringproviderqualitymeasures;seeState Report Card on Transparency of Physician Quality Information: HCI3 Improving Incentives Report,HealthCareIncentivesImprovementInstitute,December2013.

41. “NationalProgressReportandSafe-RxRankings,”SureScripts,2013(http://surescripts.com/news-center/national-progress-report-2013).

42. BasedonHealthLeadersInterstudyestimatesofthesizeoftheMedicarefee-for-servicepopulationthatwerebasedondatatheyobtaineddirectlyfromtheCentersforMedicareandMedicaidServicesandacountofMedicareACOsfromHealthQuestPublishers;see“ManagedMarketSurvey-Rx,”HealthLeadersInterStudy,January2014;AccountableCareDirectory,2014edition,HealthQuestPublishers,January2014.

43.Health Care Homes: Annual report on Implementation: Report to the Minnesota Legislature 2012–2013,MinnesotaDepartmentofHealth:HealthReformMinnesota,January2014.

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44. BasedonnumberofprimarycarepracticesthatarelistedintheNationalCommitteeforQualityAssurance(NCQA)RecognitionDirectory.TheNCQAPCMHCertificationprogramisthenation’smostpopularmedicalhomerecognitionprogram,butcertificationstandardsdifferacrossstatesandmanystateshavenotpromotedcertification;see“RecognitionDirectory,”NationalCommitteeforQualityAssurance(NCQA)(http://recognition.ncqa.org/).

45. Only~4%ofproviderseligibleforMedicare’sBundledPaymentsforCareImprovement(BPCI)haveparticipatedintheprogram,comparedwith~10%ofprovidersnationally.EligibleproviderswereidentifiedandcountedfromtheMedicareProviderofServicefilesanddefinedbytheBPCIprogramwebpagetoinclude:inpatienthospitals,inpatientrehabilitationfacilities,homehealthagencies,long-termcarehospitals,andskillednursingfacilities;see“ProviderofServiceFiles,”CentersforMedicareandMedicaidServices,May7,2014(http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/NonIdentifiableDataFiles/ProviderofServicesFile.html);“BundledPaymentsforCareImprovement(BPCI)Initiative:GeneralInformation,”CentersforMedicareandMedicaidServices,2014(http://innovation.cms.gov/initiatives/bundled-payments/).

46.Basedonhospitalnetworkdatacompiledfrom2014andindividualexchangemarketproductsanalyzedbytheMcKinseyCenterforU.S.HealthReform.Narrownetworksaredefinedashaving30–69%ofthe20largesthospitalsnotparticipatingintheinsuranceproduct’sprovidernetwork.“Ultra-narrow”networksaredefinedashavingatleast70%ofthe20largesthospitalsnotparticipating;see“ProviderInsights:Hospitalnetworks:Updatednationalviewofconfigurationsontheexchanges,”McKinseyCenterforU.S.HealthReform,June2014(http://healthcare.mckinsey.com/hospital-networks-updated-national-view-configurations-exchanges).

47. BasedonanalysisofexchangefilingsbytheMcKinseyCenterforU.S.HealthReform.

48.PreferredOne,theinsurancecompanywiththelowestratesandmostcustomersonMNsure,announcedonSeptember16,2014,thatitwillbepullingoutofthestatehealthinsuranceexchange.Thisdecisionisexpectedtoincreasetheaveragepremiumforconsumersduringthe2015OpenEnrollmentperiod.AsofAugust6,PreferredOnehad59%oftheMNsureindividualmarket;see“PoliticiansWeighinasMNsure’sLargestInsurerDropsOut,”September16,2014;“PreferredOnedropsoutofMNsureexchange,”KARE11News,September16,2014.

49.Seventeenpercentofthenon-elderly(0–64),non-MedicaideligibleuninsuredpopulationhadenrolledinexchangeproductsinMinnesota,comparedwith29%nationally,basedoninsightsbytheMcKinseyCenterforU.S.HealthReform.

50. PercentchangeinmonthlyMedicaidenrollment(comparedwithpre-OpenEnrollment)inMinnesotawas20.6%asofJuly2014,whilethenationalaveragewas13.6%,accordingtheMcKinseyCenterforU.S.HealthReform.ItshouldbenotedthatasubstantialportionofmembersenrolledthroughMNsureareenrollinginMedicalAssistanceorMNCare.

51. TheDistrictofColumbiahasMedicaideligibilitylevelsof221%and215%ofFPLforParentsofDependentChildrenandOtherNon-disabledAdultsrespectively,accordingtotheKaiserCommissiononMedicaidandtheUninsuredanalysisofMedicaidStatisticalInformationSystemsdata;see“Medicaid&CHIPIndicators—Medicaid/CHIPEligibilityLimits,2014,”KaiserFamilyFoundation:KaiserStateHealthFacts,April1,2014(http://kff.org/state-category/medicaid-chip/).

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52. In2003,MNCommunityMeasurementdevelopedanewapproachtoreportingfivekeycomponentsinone“all-or-none”diabetescarecompositemeasure“OptimalDiabetesCare.”HealthPartnersdevelopedaTotalCostofCare(TCOC)measureandaTotalCareRelativeResource Value(TCRRV)measure,whichreceivedtheNQF’sfirst-everendorsementsoffull-populationTCOCmeasurementapproachinJanuary2012.See“OurStory,”MinnesotaCommunityMeasurement(http://mncm.org/about-us/our-story/);“TotalCostofCare,”HealthPartners(https://www.healthpartners.com/tcoc).

53.Therateofdirecthospitalemploymentphysiciansisslightlylower(24%)thanthenationalaverage(25%),partlybecauseofstatelegalrulingsthatlimitphysicianemploymenttononprofitorganizations.A1955MinnesotaAttorneyGeneralOpinionstatedthatanonprofitcorporationwaspermittedtocontractwithphysicianstoprovidemedicalservicestopatients.AlthoughMinnesotaStatue§147.081prohibitsthe“unlicensed”practiceofmedicine,itdoesnotexplicitlyprohibitthecorporatepracticeofmedicine.See“PhysicianList,”SK&A,May2014(http://www.skainfo.com/physician-mailing-lists.php);“RecentDistrictCourtCaseHighlightsStateVariationinApplyingCorporatePracticeofMedicineandGlobalBillingRestrictionstoMRIProviders,”EpteinBecker&Green,P.C.,May6,2014.

54. MinnesotaalsohasaMedicaidACOdemonstrationthatincludesnineprovidersandcovers145,000beneficiaries.ThisMedicaidACOservesasthefoundationfortheMinnesotaSIMAccountableCareHealthModel.See“StateInnovationModelGrant–MinnesotaAccountableHealthModel,”HealthReformMinnesota,July,2014(http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=SIM_Home).

55. Thestate’skeyprogramsincludeMinnesotaSeniorHealthOptions(MHSO),SpecialNeedsBasicCare,andtheMedicareAdvantageDualEligibleSpecialNeedsPlans(MAD-SNP).Theseprogramshavereadiedthestatetobeanactiveparticipantandfront-runnertoreceivefederalfundingthroughCMSdemonstrationprogramsthatfocusonthispopulation.Minnesotareceived$1MthroughCMS’sDemonstrationtoIntegrateCareforDualEligiblesin2011,1of15statestoreceiveprogramfunding.Itthenwentontobecome1of9statestoreceiveCMSapprovaltoimplementademonstrationtointegratecareandalignadministrativefunctionsfordualeligiblesforthreeyearsthatbeganinSeptember2013.MNplanstousethisdemonstrationtocombineexistinginitiatives,suchasMedicaidHealthCareHomes,tobettercareforthisat-riskpopulation.SeeMinnesotaDepartmentofHumanServices(http://mn.gov/dhs/);Musumeci,MaryBeth,“FinancialandAdministrativeAlignmentDemonstrationsforDualEligibleBeneficiariesCompared: StateswithMemorandaofUnderstandingApprovedbyCMS,”KaiserFamilyFoundation,July24,2013.

56.In2011,afterHMOsreportedstrongprofitsof7.9%frommanagedMedicaidproductsin2010,thestateurgedthefourlargestMedicaidhealthplanstolimittheirnetincomeforMAandMNCareto1%andinstitutedacompetitivebiddingprocessformanagedMedicaidcontracts.ThestatefundedaLegislativeAuditortocontractwithoutsidefirmstoperformindependentauditsoftheMedicaidhealthplans.Itisprojectedthatthesenewcontractswillyieldsavingsof~$600Mbytheendof2013.

57. TheMinnesota2008HealthCareReformActrequiredthatallMedicaidandCHIPenrolleeshaveaccesstohealthcarehomes,designedtoprovideagreaterextentofcarecoordinationtobeneficiariesinordertoreduceacutecarecosts.And,startingin2013,sixACOshaveenteredintosharedsavingsandriskagreementswiththeMedicaidprogram,creatingadditionalopportunitiesfortheprogramtoproducesavingsthroughlowerutilizationandbetterqualityofcare.SeeJenniferN.Edwards,“HealthCarePaymentandDeliveryReforminMinnesotaMedicaid,”The CommonwealthFund,March2013.

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58.ThesuicidepreventionprogramunderMDH’sInjuryandViolencePreventionUnit,forexample,usesapublichealthapproachtopreventingsuicidesbysupportingandcoordinatingstate-fundedsuicidepreventionactivitiesandprovidingtechnicalassistanceanddatatosupportcommunity-basedprograms.MDHalsohasanumberofinitiativestargetingspecificat-riskpopulations,suchastheRefugeeHealthResourceGroupandtheCenterforVictimsofTorture.See“ViolencePrevention,”MinnesotaDepartmentofHealth(http://www.health.state.mn.us/injury/topic/topic.cfm?gcTopic=7).

59.Centers for Disease Control and Prevention (CDC): Behavioral Risk Factor Surveillance System Survey Data,Atlanta,Georgia:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,2009–2012.

60.Althoughratesofpreventivescreeningandimmunizationinadultsarebetterthanthenationalaverage,therateofchildhoodimmunizationisworse,at78%,comparedwith83%nationally,in2013.

61.The2008HealthCareReformActcreatedtheStatewideHealthImprovementProgram(SHIP),whichcoordinatesprogramswithlocalcommunitiesthroughitsOfficeofStatewideHealthImprovementInitiativesacrossanumberoffocusareas:tobacco,obesity,nutrition,physicalactivity,farm-to-schoolfood,saferoutestoschool,schoolhealth,andschoolmeals.MDHhasalsoissuednewimmunizationlawsforschools,childcare,and,forthefirsttime,earlychildhoodprogramstobeginSeptember2014.See“StatewideHealthImprovement,”HealthReformMinnesota(http://mn.gov/health-reform/topics/prevention/statewide-health-improvement/);“New ImmunizationLawsforSchools,ChildCare,andEarlyChildhoodProgramsBeginSeptember2014,”MinnesotaDepartmentofHealth,August1,2014(http://www.health.state.mn.us/divs/idepc/immunize/immrule/newlawfs.html).

62.Althoughthestatewidechildpovertyrateisjust15%,thisratevariesgreatlybyrace:white(9%),AfricanAmerican(46%),Asian(23%),AmericanIndian(49%),andHispanic(30%).MNhasthehighestrateofAsianchildrenlivinginpoverty.Additionally,26%ofallimmigrantchildrenarelivingin poverty. See Minnesota Kids County 2013: A data visualization of child well-being,Children’sDefenseFund,April2013.

63.AsdefinedbytheStateCommunityHealthServicesAdvisoryCommittees(SCHSAC).See“SCHSRACRegionswithCommunityHealthBoards,”MinnesotaDepartmentofHealth,May2014(http://www.health.state.mn.us/divs/opi/pm/schsac/docs/ataglance_schsac.pdf).

64.Notethatwedon’tlookatprogresswithimplementationofreform.

65.AsofDecember2013,322primarycareclinics—roughly43%ofthetotalinthestate—hadbeencertifiedasHealthCareHomes.Nearlytwo-thirdsofthesearesubmittingclaimsforcarecoordinationpayments.Pilotsforcommunitycareteamshavebeentestedinthreecommunities,andaseriesoftoolsandknowledge-sharingprogramshavebeendeveloped.SeeHealth Care Homes: Annual Report on Implementation: Report to the Minnesota Legislature 2012–2013, MinnesotaDepartmentofHealth:HealthReformMinnesota,January2014.

66.PubliclysourcedSHIPfundingwasreducedby70%inthefiscalyear2012–13.CDCfundingtolocalcommunitiesisbeingreducedduetonationalfundingreductions,andissettoendinSeptember 2014. See The Minnesota Statewide Health Improvement Program—Progress Brief—Year 2,MinnesotaDepartmentofHealth:HealthReformMinnesota,March2,2012;“CommunityTransformationGrant,”MinnesotaDepartmentofHealth,May29,2014(https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=minnesota%20community%20transformation%20grant).

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