Utah holds a unique distinction among U.S. states: It has the healthiest population and the lowest per-capita health care costs, according to some measures. A grid analysis of health status against expenditures, based on 2009 data from the Kaiser Family Foundation and 2013 data from the United Health Foundation, puts Utah in the sweet spot: the upper right quadrant. (See graph below.) Its per-capita costs are just over half those of equally healthy Massachusetts ($5,013 vs. $9,278), which occupies the most expensive quadrant, the lower right.
Experts haven’t quite uncovered the secret to Utah’s success — but the state’s people, systems, dollars, and data certainly matter.
A Profile of Utah’s Population
Utah’s advantage in health starts with demographics. Its population is the youngest in the union by several years, with an average age just under 30, according to U.S. Census figures. (The national average is 37.4.) It’s also a relatively well-educated state, ranking 7th in percentage of high school graduates and 17th in percentage of residents with at least a bachelor’s degree. Both youth and high educational levels correlate with better population health.
Currently number 5 on United Health Foundation’s America’s Health Rankings, Utah posts impressively low numbers on smoking, preventable hospitalizations, and percentage of children living in poverty. But it has challenges: a high rate of drug-related deaths (ranked 46th out of 50 states); a shortage of primary care physicians (ranked 44th); and, according to federal surveys, the highest rate of mental illness in the United States.
A preponderance of Mormons explains some of Utah’s overall edge on health. Brent James, MD, executive director at Intermountain Health Care’s Institute for Health Care Leadership, says that 60% to 70% of the state’s 3 million people identify as Mormon, even if they don’t attend church regularly, and most of them follow the church’s dietary and behavioral restrictions, which include no tobacco, alcohol, or recreational drugs. The faith also encourages large families and strong social networks, both of which provide support when people get sick.
Vivian Lee, MD, CEO of University of Utah Health Care and dean of the UU School of Medicine, says the social structure in Utah contrasts sharply, for example, with that of New York City, where in 2011 she left a senior post at NYU’s Langone Medical Center, enticed by UU’s high rankings on measures of mortality, patient safety, and patient satisfaction. “Patients in Utah don’t die in the ICU,” she says. “They go home. There’s much higher use of home health and hospice.”
The Systems Matter, Too
Can anything about Utah’s enviable health care environment be exported to other regions? Or do its clean-living people deserve all the credit?
“Even after you control for [Utah’s] population, we still have really good outcomes and low costs,” says James, renowned for his work on improving clinical quality by reducing variations in medical practice. Intermountain, the state’s largest hospital system, has hosted thousands of clinicians and health care executives, from all over the world, at the Institute for Health Care Leadership. They learn how to apply Intermountain’s quality-improvement and cost-control strategies to everything from prostate surgery to the care of newborns.
A recent change — putting some preemies on pressurized nasal oxygen until their lungs mature, rather than using mechanical ventilation — both improved the infants’ outcomes and cut costs substantially. “Intermountain took a $340,000 margin hit, and then rolled it out across the state and turned it into a $5 million loss,” James says, only half joking. Intermountain is also an insurer — the largest in the state — and thus ultimately benefits from saving money on care.
The lessons to learn from Utah don’t end there. When Utahans get sick enough to be hospitalized, they are treated in the least aggressive hospitals of any state, according to the Dartmouth Atlas of Healthcare’s Hospital Care Intensity index, which defines “aggressive” hospital care on the basis of two variables: how many days patients spend in the hospital, and how often they see a physician while they’re there. Even the most aggressive hospital in Utah, Intermountain-owned LDS hospital in Salt Lake City, is only in the 14th percentile. (New Jersey’s hospitals are the most aggressive.)
Other notable facts in the Dartmouth atlas: Utah hospitals had 142 medical discharges per thousand Medicare enrollees in 2012, compared with a national average of 209 discharges. And hospitalized Medicare patients in Utah went home sooner: an average of 0.83 inpatient days per Medicare enrollee, versus 1.42 nationally. However, when it comes to surgery, Utah’s utilization is actually higher: Dartmouth’s analysis shows that Utah hospitals had higher-than-average surgical discharges for Medicare patients: 85.5 per thousand enrollees, compared with 80.4 nationally.
Dollars and Data
Utah’s health care system also benefits from a strong financial history and a forward-looking approach to the use of data.
Intermountain had unusual financial health at its inception, says Robert Huefner, professor emeritus of political science at UU and a longtime Utah health scholar. Once the health system for the Mormon Church, Intermountain became an independent not-for-profit in 1975. “Most shifts of hospitals from church to non-church ownership have resulted from a sale, so they usually start out with a fair amount of debt,” because the purchasing party finances the sale through borrowing, he says. “The church didn’t sell Intermountain, so it’s always had a firmer financial base.”
Historically a leader in the medical informatics field, Intermountain developed one of the first electronic health record (EHR) systems in the country and has spent decades mining that system’s data for clues on how to improve care. It’s currently working with a major health care software vendor to create a new commercial version of its EHR. And the University of Utah is developing a state-of-the-art cost accounting system — potentially transformative in an industry notorious for its shortcomings in tracking costs. “You can’t manage what you can’t measure,” says Vivian Lee.
Lee also argues that it’s crucial to make doctors aware of the costs of the care they provide. “You have to get data into clinicians’ hands,” she says. “Our orthopedic surgeons were surprised to discover that there’s a threefold difference in cost between the most expensive hip prosthesis they use and the least expensive one.” The accounting system can capture costs for each item used in care, each clinician’s time, and other contributors to the overall cost of services. Combined with clinical data, it can help determine which expenditures improve quality and which can be trimmed without harming patients.
Brent James says any institution willing to put in the time, money, and effort can develop a “cost master” like UU’s, and start identifying variations that run up cost without improving quality.
Demographics, systems, finances, and well-leveraged data all clearly play a role in Utah’s health care success story. But Huefner would like to see an outside party, with no vested interest in the outcome, study the state carefully and come up with a definitive explanation of what makes Utah different. “We don’t really know why we rank so well,” he says. “We have the best data sets in the world, so I don’t know of a better place to do that analysis.”
This article originally appeared in NEJM Catalyst on November 25, 2015.