US Needs to Rethink Spending for Chronic Illnesses, Dartmouth Study Says

“This excessive and misplaced use of resources is only one manifestation of a totally chaotic health care system,” said Alfred Munzer, MD, President of the Medical Staff and Director of Pulmonary Medicine at Washington Adventist Hospital in Takoma Park, Md., and past President of the American Lung Association. “Medical technologies are developed and used in an ethical and moral vacuum. The effect of new technology on a patient’s quality of life, and the implications for the family, are never assessed.”

The study goes on to say that two factors influence decisions about caring for the chronically ill: physicians and patients alike believe that using every available resource produces better outcomes; and based on this assumption, the supply of resources, not the incidence of illness, drives use of services, so in essence their presence creates their own demand. Therefore, areas with more resources per capita have higher costs per capita.

‘Learn to Make Tough Decisions’

John C. LaRosa, MD, President of SUNY Downstate in Brooklyn, NY, has a somewhat different take on the problem. “This country hasn’t faced the problems of what to do about the chronically ill who have no hope of recovery. We need to learn how to make decisions about who should be treated and who should be allowed to die comfortably in nursing homes, hospices, or at home. Moreover, the Dartmouth report said nothing about what patients and their families want.”

The researchers studied patients with chronic illness during their last two years of life because that’s where Medicare spends 30% to 35% of its total expenditures. However, patients don’t necessarily benefit and the costs of such care are high.

“Hospitals are not satisfied with being community hospitals but strive to be tertiary medical centers. Few of them focus on care of the chronically ill. Palliative care is still in its infancy and not generally accepted by the medical profession. Physicians are rewarded for procedures, not for time spent planning for chronic care,” said Dr. Munzer. “What’s more, medical education is still oriented to hospital and acute care. Interns and residents order tests and procedures to benefit their education and to assure their professors that they have left no stone unturned in the quest for diagnosis and treatment.”

Dr. LaRosa agreed. “Physicians are trained to prolong life, but I know plenty of doctors who are perfectly comfortable telling patients and families that further treatment will not do any good. But a lot of them just don’t want to hear it.”

What Ought to Change

“This carries an important implication for health-care policy: Health-care organizations serving low-cost regions aren’t withholding needed care,” said Elliott S. Fisher, MD, MPH, Senior Associate at the VA Outcomes Group, Professor of Medicine and Community Family Medicine at Dartmouth, and co-author of the study. “On the contrary, they are more efficient. They achieve equal and often better outcomes with fewer resources and offer a benchmark of performance toward which systems should strive.”