A new Dartmouth Atlas study released this morning found that the care of Medicare beneficiaries with one or more of twelve chronic illnesses accounts for more than 75% of all U.S. health care expenditures. Among people who died between 1999 and 2003, per capita spending varied by a factor of six between hospitals across the country. Average utilization and spending varied from state to state, from region to region within states, and from hospital to hospital within the same regions. Spending was not correlated with rates of illness in different parts of the country; rather, it reflected how intensively certain resources – acute care hospital beds, specialist physician visits, tests and other services – were used in the management of people who were very ill but could not be cured. Since other research has demonstrated that, for these chronically ill Americans, receiving more services does not result in improved outcomes, and since most Americans say they prefer to avoid a very “high-tech” death, the report concludes that Medicare spending for the care of the chronically ill could be reduced by as much as 30% – while improving quality, patient satisfaction, and outcomes.
Staggering variations in how hospitals care for chronically ill elderly patients indicate serious problems with quality of care and point toward unnecessary spending by Medicare. Lower utilization of acute care hospitals and physician visits could actually lead to better results for patients and prolong the solvency of the Medicare program. The study calls for overhauling how the nation manages chronic illness, and proposes that hospitals take leadership in redesigning how they care for the chronically ill.
Three issues drive the differences in the cost and quality of care, according to principal investigator John E. Wennberg, M.D., M.P.H. “Variation is the result of an unmanaged supply of resources, limited evidence about what kind of care really contributes to the health and longevity of the chronically ill, and falsely optimistic assumptions about the benefits of more aggressive treatment of people who are severely ill with medical conditions that must be managed but can’t be cured,” said Wennberg.
The attention grabbing table, also cited in the Wall Street Journal this morning, presented the variations in average days of inpatient care at Council of Teaching Hospital (COTH) academic medical centers for all decedents in the last six months of care. NYU Medical Center topped this list, with 32.1 days of care, compared to Scott and White Memorial in Temple, TX, with 9.2 days of care.
As we’ve written before, extreme variations in the quantity of service raises questions…”why?” being the most frequent one. While some bluster on about lawsuits, the real culprit in the cost gallop may be in being able to manage chronic and end of life care without, overall, making a positive difference. The question being asked by employers and others is simple: for the $1.6 trillion spent on healthcare in the US, what are we getting? Where are we making a difference? Where should we do less “treating” and more simple “caring”?