Evaluating US county health-care system performance and key associated factors (2014-19): a Triple Aim framework analysis

Abstract

Background: The Triple Aim of health care-defined as the simultaneous pursuit of positive patient experience, positive health outcomes, and low spending-has been established as a goal for health-care systems. The US health-care system has high rates of health spending and poor health outcomes relative to other countries, although there is substantial variation within the country at both state and county level. Assessing which US counties have been most successful in achieving the Triple Aim, and which implemented policies are associated with high performance, could be valuable for developing policies that improve health care nationwide. In this study, we aimed to quantify progress towards the Triple Aim at the US county level.

Methods: In this ecological analysis, county-level data on each component of the Triple Aim were combined to assess health-care system performance from 2014 to 2019. Patient experience was assessed via a composite indicator, health outcomes via life expectancy, and low spending via purchasing power-adjusted health-care expenditure per capita. For each county, overall unadjusted performance scores were generated from data on each of the three aims. Adjusted performance scores were then calculated that controlled for key county characteristics outside of the control of the health system. Linear regression was used to assess which policy-relevant factors were associated with the best-performing counties.

Findings: Counties with higher unadjusted performance scores tended to have populations that were more educated, wealthier, had a higher proportion of residents in urban households, lower rates of obesity, and lower rates of smoking than counties with lower scores. After adjusting county scores for these underlying characteristics, counties in Rhode Island, Iowa, Idaho, Virginia, and Hawaii led in progress towards the Triple Aim, whereas the District of Columbia, Alaska, Delaware, Mississippi, and Oklahoma had the lowest scores. Regarding policy-relevant factors, progress towards the Triple Aim was associated with a prioritisation of managed care, expanded Medicaid coverage, and competitive hospital and insurance markets.

Interpretation: These findings highlight health system disparities and policies that were associated with health-care system performance. These results can help policy makers to develop strategies that reduce health-care spending, increase access to and quality of care, and ultimately improve health outcomes.

Funding: Peterson Center on Healthcare and Gates Ventures.