Part Two Summary and Brief Comments

Overall, as in our first Community Health Checkup on diabetes, we find that Better Health’s partner practices compare favorably to national health plan data reported by NCQA, on all NCQA standards and across all insurance sub-groups. We also find that partner practices in the region perform substantially better on Better Health’s Process Standards as compared with Outcome Standards. In addition, we are reassured to find few disparities in Care Processes across our patients of different races, income, or educational attainment. Finally, we are pleased to report unanticipated improvement in the region, both on our Care Processes and our Outcomes and across most socio-economic sub-groups. By using Better Health’s data to identify Exceptional Achievers and Exceptional Improvers, we believe that we can accelerate improvement throughout the region.

Despite these successes, there remains much room to improve. Half of the region’s patients with diabetes fail to meet all four of our Care Process Standards, and more than 60% fail to meet four or more of our five Outcome Standards. Outcomes are poorer for minorities, those with lower incomes and educational attainment, and for our Medicaid patients and the uninsured. An even greater challenge is that our Medicaid and uninsured patients failed to improve in the current Checkup, in contrast to the improvements noted for minorities, the poor, and those with less education. Data from the Dartmouth Atlas Project challenge Greater Cleveland to reduce its rate of “preventable hospitalizations” and amputations, important outcomes we currently are not measuring in Better Health.

In addition to motivating system and practice-level improvement among our partners and their patients, region-wide improvement also will depend on others in the Greater Cleveland community and policymakers in Columbus and Washington. Increasing rates of chronic diseases like diabetes, accompanied by increasing rates of unemployment, uninsurance, and underinsurance, have resulted in rising out-of-pocket spending. Policymakers and insurers should be aware of the ample evidence that out-of-pocket expenses (deductibles, co-payments, and co-insurance) disproportionately burden people with chronic conditions and discourage adherence to drugs that prevent disease progression (see, for example, Paez, Zhao, and Hwang. Health Affairs. 2009; 28: 15-25). Value-based insurance designs should be adopted that subsidize high-value chronic care while increasing cost sharing for elective services with unproven benefit. In addition, the community should recognize that many chronic conditions, including diabetes, can be attributed in large part to lifestyle habits and better controlled with improved lifestyles, including avoidance of smoking, increased exercise, and good nutritional habits. To the extent that our environment, and the design of insurance benefits, can foster healthier lifestyles, better health will result. At a community level, this can include the support of bike paths, sidewalks, and parks; increased opportunities for execise at workplace facilities, improving access to healthy foods, and establishing policies that promote community wellness. Everyone can contribute to making Cleveland healthier, and with better health, we should make a Greater Cleveland.