Why It Matters
"While there is no single path to improvement, [Western New York, Southern Arizona, and West Central Michigan] provide an evidence-base for approaches all communities should consider as they strategize for the new era of sustainable, high-quality health c
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Moving to High-Value Health Care: Case Studies of Three Excelling US Regions

By John Gauthier | Monday, May 12, 2014

We all feel it: Business as usual in American health care is vanishing quickly, forcing providers, insurers, health systems, employers, and public agencies to adopt new practices and find business models that will enable them to survive, if not thrive. Some leaders have likened this prospect to “crossing a rushing river without seeing the next stone.”

Change, of course, is imperative. The US has the world’s most expensive health care system, yet it produces poorer quality and health outcomes than our lower-spending counterparts. As a whole, one might say the US health system illustrates the antithesis of the Triple Aim — lower quality of care, greater spending, and worse health outcomes.

In 2012, the Commonwealth Fund released its first nationwide Scorecard on Local Health System Performance (“Local Scorecard”), which ranked 306 US regions on 43 indicators of health care access, quality, efficiency, and outcomes. The Scorecard documented staggering variation across the 306 regions, including differences between highest- and lowest-performers that are:

  • Three-fold in Medicare spending per beneficiary
  • Greater than three-fold in potentially preventable deaths
  • Four-fold in infant mortality
  • Six-fold in unnecessary hospitalizations
  • Nearly ten-fold in adults without health insurance
  • Ten-fold in suicide rates

How could such huge differences exist? What are stronger performers doing that others may find helpful? How does local context influence performance and improvement strategies?

The Commonwealth Fund recently published a series of case studies on three “positive deviant” regions — i.e., places performing well on the Local Scorecard despite challenges associated with poorer performance, such as high poverty rates — that aim to address these questions. Delving into the Scorecard’s rankings, my colleagues (Douglas McCarthy, Sarah Klein) and I sought regions with excellent (top-quartile) overall performance, a medium-to-large size (over 1 million) population, and greater socioeconomic challenges than other top performers. We also prioritized diversity in our sample to reflect multiple contexts and maximize the instant relevance of our findings to more American communities.

Ultimately, we selected three “positive deviant” regions fitting these criteria — Western New York, Southern Arizona, and West Central Michigan (see map below) — to feature in the case studies.

Each region has unique history and context that emphasize the differences between them, yet similarities also exist:

  • All are anchored by a diverse, mid-size city (Buffalo, NY; Tucson, AZ; Grand Rapids, MI) that happens to be each state’s second-largest metropolitan area.
  • All have similarly-sized populations (between 1.2 and 1.4 million), positioning them well for comparison.
  • All have higher rates of poverty than other top-performing regions with populations over 1 million.  


Our team spoke with an array of stakeholders in each region, including hospitals, primary care providers, health plans, employers, public health departments, and others. Beyond profiling each region’s story, we wrote a synthesis report to highlight themes across all three that may explain their unexpected success:

  • Coordinate improvement efforts and expand collaboration among providers and insurers to improve the quality and efficiency of care.
  • Make regional investments and encourage collaboration when it comes to developing information technology and engagement of community organizations.
  • Exhibit a commitment to improving care — particularly access to high-quality primary care and preventive services — for underserved, vulnerable populations.
  • Take advantage of payer concentration, as well as physical environment and geography.
  • Leverage sources of pride and community assets to build social capital and will for health promotion.
  • Link health and health care to a common desire to overcome economic challenges and advance the well-being of their populations.
  • Pursue alternative, accountable care contracts — public or private — that align incentives so multiple stakeholders can partner in acting as one team.

The case studies also introduce how these regions have excelled in different areas, such as:

  • Reaching the underserved through expansion of Federally Qualified Health Centers (AZ, NY)
  • Conservative resource allocation through local certificate-of-need (MI)
  • Telemedicine programs (AZ)
  • Local health promotion initiatives (AZ, NY)
  • Systems enabling the exchange of electronic health information across the region (MI, NY)
  • Industry-leading hospice programs (MI)

While there is no single path to improvement, these three regions provide an evidence-base for approaches all communities should consider as they strategize for the new era of sustainable, high-quality health care. Achieving the Triple Aim for populations does not happen overnight, but it does happen one step, conversation, decision, and initiative at a time.

So what’s the first step? Start a conversation with leaders from local “competitors” about your vision for a healthier community. Find your shared sources of professional and community pride. Identify your greatest cultural strengths, local resources, and community assets. Talk about what needs are most dire for your patients, communities, and own families. You just might find a common ground on which to stand and work together.

Sandy Cohen, MSW, MPH, is a Research Associate on the Results and Evaluation team at IHI. He has collaborated on several qualitative studies of high-performing US health systems through grants from the Commonwealth Fund to IHI.

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