A new study from Dartmouth Medical School documents “staggering variations in how hospitals care for chronically ill elderly patients.” The study points to problems with quality and faults Medicare for unnecessary spending. It goes on to say that less use of acute care hospitals and fewer physician visits could lead to better results for patients.
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September 2006The study was done at Dartmouth’s Center for Evaluative Clinical Services under the direction of John E. Wennberg, MD, MPH. He said that three issues drive differences in cost and quality of care: an unmanageable supply of resources; limited evidence about what kinds of care really benefit the chronically ill; and falsely optimistic assumptions about conditions that cannot be cured.
The Numbers
The study looked at the records of 4.7 million Medicare enrollees who died of chronic disease between 2000 and 2003. The researchers came to the conclusion that Medicare could have saved $40 billion if all hospitals practiced the high-quality, low-cost standard set by the Salt Lake City region. It also found that hospitals that treat patients more intensively and spent more Medicare money did not get better results. In fact, regions with the best quality and outcomes used the fewest resources: Rochester, Minn., and Portland, Ore., in addition to Salt Lake City, Utah. Patients there are admitted less frequently to hospitals, spend less time in an ICU, and see fewer specialists.
“This excessive and misplaced use of resources is only one manifestation of a totally chaotic health-care system.” – —Alfred Munzer, MD
The variation among academic medical centers for the average number of hospital days during the last six months of life ranged from 12.9 days at St. Mary’s Hospital in Rochester, MN, to 23.9 days at New York Presbyterian Hospital. The University of California–Los Angeles had the highest number of ICU days at 11.4—3.5 times higher than University of California-San Francisco (3.3 days). Medicare enrollees at New York University Medical Center had the most physician visits (76.2), the Robert Wood Johnson Hospital in New Brunswick, NJ, had the next most (57.7). At the University of Kentucky in Lexington there were only 18.6 physician visits.
Dr. Wennberg said that resources per capita devoted to managing chronic illness are increasing steadily each year—13.6% more ICU beds in 2003 than in 2000, 13.4% more for medical specialists, and 7.7% more for primary physicians. Acceleration was greatest in regions already using the most care.
Causes of the Trends
Medicare and other payers are part of the driving force behind the increases. “They encourage overuse of acute care hospital services and proliferation of medical specialists. The care of people with chronic illness accounts for more than 75% of US health-care expenditures, indicating that overuse and overspending is more than a Medicare problem,” said the report.
“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.”
The report should end the more-is-better myth in health care, said Donald M. Berwick, MD, President and CEO of the Institute for Healthcare Improvement. It also points to needed fundamental changes in the way the millions of chronically ill Americans are cared for. Whatever investment is made in their end-of-life care should be of the highest quality, the most useful, and most cost-effective—for instance, a better home health-care system.
Dr. LaRosa said that the longer people live, the more medical resources they will consume. Thus preventive medicine doesn’t save money over the long run. “Nothing we do, no social policy anyone comes up with, will decrease health care costs over the next 20 years.”
The payment system needs to be changed as well, the Dartmouth researchers believe. The report notes that when payment is based solely on utilization, hospitals that reduce the number or length of stays lose money. The authors call for a reimbursement system that rewards rather than penalizes provider organizations that successfully reduce excessive use of services and that institute broader strategies for managing patients with chronic illness.
Extensive research has documented that greater use is associated with worse outcomes, poorer quality, and lower satisfaction with care. To this end, the report said, academic medical institutions and federal agencies such as the National Institutes of Health need to define efficient clinical practices: whom to hospitalize, when to schedule a physician visit, and when to refer a patent to a medical specialist, home health agency, or hospice.
Dr. Munzer summed it up: “To bring about a change in physicians’ attitudes, we must reassess their motivation for entering the profession. We need physicians who not only have a head but also a heart.”
©2006 The Triological Society
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