Monday, April 09, 2007

One variation or another

A big topic in the medicine world is whether the variation in how care is delivered, particularly near the end of life, is symptomatic of overuse, underuse, misuse, and waste in the health care system. The Dartmouth Atlas Project, run by the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, spends its time on the question of how medical resources are distributed and used in the United States. Here's the premise:

The project offers comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians, in order to provide a basis for improving health and health systems. Through this analysis, the project has demonstrated glaring variations in how health care is delivered across the United States.

Now, as someone trained in statistics, I get a little nervous when someone in academia talks about "glaring variations". It might suggest a degree of hyperbole that is not consistent with rigorous analysis. But upon further review, it is hard to find fault.

One study, for example, showed a six fold variation in per capita hospital spending on people with chronic illnesses who died between 1999 and 2003 in hospitals across the country. The spending was not correlated with the rates of illness, but seems instead reflect "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." The authors' conclusion is that the Medicare system gives inappropriate financial incentives to take care of chronic care patients in a hospital setting, where overly expensive end-of-life care will be delivered. In essence, this suggests that we use too many specialists and high-priced equipment, tests, and other services for people who should really be taken care of in another setting.

This study points out the wide variation in cost of care for these end-of-life patients, and then it also points out that the hospitals that treat patients more intensively and spend more Medicare dollars did not get better results. In a variant on "if you build it, they will come", the report concludes:

The study paints a picture of the health care system in disarray over the treatment of chronic illness. There are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness. Lacking this, two factors drive decisions:

Both doctors and patients generally believe that more services - that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc. - produces better outcomes.

Based on this assumption, the supply of resources - not the incidence of illness - drives utilization of the services. In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.

These conclusions are not universally accepted. While they acknowledge that some variation is the result of available resources, some observers feel that the variation in these costs is explained by other factors not captured in the folks at Dartmouth. Matthew Holt provides a nice summary of these arguments and commentary on them here and there are lots of thoughtful responses here.

I come to this whole issue very late and after other people have dissected it to death. I'm not sure I have much to offer. Let's assume that the Dartmouth conclusions are correct and that much of the variation in health care costs is supply-driven. As a person involved in policy-making in other arenas, I am left wondering what one would actually do with this information if you could "pass a law". If you were in the government, would you act to apportion hospital and physician resources across the country? Highly doubtful. Would you change the method of reimbursement so that there would be a capitated payment for each type of chronic illness? I feels like that has been tried, and the public objected to someone -- anyone -- being the gatekeeper for how their care would be managed. Would you create a national standard on what services could be provided at the end of life, i.e., ration care? Politicians who have suggested that do not get elected. Could we adjust Medicare payments so that they provide ample payment for less acute care versus specialty care? That seems like a worthy goal for lots of reasons, but it is unclear to me how much it would do much on this front.

Please understand that I am not arguing against efforts to reduce overuse, misuse, underuse, or waste in any given hospital. I strongly favor that. I am just left wondering what I would do as a policymaker with this information. In the absence of other actions, I would, however, shine sunlight on these variations. Peer pressure and public exposure might be the best medicine.

Further, if I were a regional insurer I would start by publicly posting this kind of Medicare data to compare individual hospitals within my region with one another. In so doing, I would attempt to create pressure on my local institutions from the people (i.e., employers) who pay for most of the costs of health care. (Unfortunately, you can't post your own insurance company's cost data because it would demonstrate the unwarranted differences in reimbursement rates you pay to each of your region's providers!)

Are there other ideas from my thoughtful readers out there?


Anonymous said...

How about suggesting this to the Quality and Cost Council?

Anonymous said...

I thought I just did . . .

Anonymous said...

I would like to offer a few thoughts on this. First, I think we should evaluate and understand how our friends in Europe, Canada, Japan, etc. handle this issue. Since many people constantly point to these healthcare systems as far more cost efficient than ours, maybe we can learn some things that could be replicated here.

Second, I think we need a politically independent scientific Board modeled after the Federal Reserve that could evaluate new biotech drugs and new surgical techniques and decide whether or not we should pay for them based on cost-effectiveness.

Third, I think the same Board, in consultation with the medical societies, should develop national guidelines that would speak to what constitutes good, sound medical practice with respect to end of life care. For example, perhaps patients with advanced Alzheimer's or dementia should not receive any interventions like bypass surgery, kidney dialysis, hip or knee replacement, chemotherapy, etc. Maybe such interventions should also be withheld from people beyond a certain age (90?) unless they can self pay. I also think living wills and advance medical directives should be routine and required as a condition of insurance to eliminate often unwanted care at the end of life. We always hear that 5% of the patients account for 50% of the dollars spent, and a lot of it is here at the end of life. With 47 million people still without health insurance, this is the first place we should be looking to free up resources, in my opinion.

Anonymous said...

See my comment here.

Anonymous said...

Interesting comments that illustrate how complex the design and delivery of health care has become in this century. It is hard to argue that the science of medicine has not made dramatic improvements over the past few decades, but the art of delivering the science has regressed. Frankly, it is the business model that is broken. Until we develop a system that enables us to effectively deliver the science the system will continue to be inefficient and yield less than satisfying results. There are some interesting postings with suggestions, but perhaps the first step should be for us to step back and define the objectives of the system. Success is difficult to chase when it is not defined

Anonymous said...

Want to try defining it?

Jon said...

This issue is very interesting to me, and has a variety of angles you can approach it from. When I read your initial post the first thing I thought of was the oft-repeated (in the hospital) statistic that 50-- or is it 80-- percent of medicare dollars are spent in the final six months of life. Having never seen this number in print, I went looking for it. The best I could find was this quote from a USA Today article about end-of-life care and the Dartmouth Atlas Project:
"Estimates show that about 27% of Medicare's annual $327 billion budget goes to care for patients in their final year of life."

Which takes on a more significant point when you read the entire article about the wide divergence in cost/type of end-of-life care availible in different states:

To me this small chip of the iceberg provides a vingette for the problem we face here. Anyone who has spent time in a hospital realizes there is a great deal of wasted money on terminally ill (and often unconscious) patients. But who's job is it to cut those costs, and make those tough decisions about who gets a ventilator and who doesn't? I know that change can be made with individual doctors, but without a national discussion or consensus I can't see any change being made quickly.

Toni Brayer, MD said...

Since Medicare/Medicaid are the big payors and drive the nation's health policy, we need to start there, The incentives drive overuse. Medicare pays certain cities and regions more for care and those cities have higher utilization and cost. Medicare also pays more for patient outliers (ie: "sicker") so the incentives for more and more proceedures (tests, ICU admits, surgeries, technology) also drives cost without better outcomes. We are the only Western nation without a streamlined health policy built on primary care. No-one is without blame. The Politicians, Big Pharma, AMA, American Hospital Association, Specialty Societies, AARP are all part of the system that keeps us from tackling the big, thorny issues.
I like the idea of a politically independent scientific board as bc mentioned. Can we really keep politics and greed out of it?

Roy M. Poses MD said...

On one hand, common sense suggests that there is a lot of over-use, under-use, and mis-use of care in the US.

On the other hand, variations studies are not very good in pointing out who got which kind of care. In particular, retrospectively studying care received by patients who died is bound to cause confusion.

The best published discussion of why this is so is here:
The citation is Bach PB, Schragg D, Begg CB. Resurrecting Treatment Histories of Dead Patients: A Study Design That Should Be Laid to Rest. JAMA 2004; 292:2765-2770.

The main problem with studying people who died is that many people die unpredictably, while many people who also appear to be seriously ill and about to die don't die.

A cohort of people who died will include a difficult to characterize mixture of people of died unexpectedly and the chronically ill whose deaths were not surprising. Variation in the previous care of such patients may reflect this mixture. People who appeared healthy, and then developed a sudden acute illness, or had acute trauma, are often, and probably should be treated vigorously. Hospitals may vary in what proportion of such patients they see. For example, hospitals with trauma units may have a higher proportion of them.

The only real way to study variation so that the results would be interpetable would be to study very similar groups of patients with very similar problems treated in different institutions. Such prospective studies could separate variations in decision making from variations due to differences in patient populations.

But most variations studies are retrospective, and are liable to compare different sorts of patients seen in different places. One can never be sure if the variations they study are due to variations in care, or variations in patients showing up to receive care.

Anonymous said...

Interesting challenge! I wish I had more time to think about the root cause of the issues. Everything I read about the state of our health care systems seems to focus on the symptoms of the disease. Actually the symptoms are presented as problems and the discussion quickly moves to blame. While it is difficult to articulate exactly what our health care system should be ideally, the consumer should define the purpose of the health system. Market forces should drive the individual industry contributors in a direction that is satisfying to the consumer. Fulfillment of consumer needs will ultimately lead to satisfaction levels that determine if you become a long-term player in the industry. Consumers should expect a mixture of science, which drives outcomes, and elements of the art that drives the feel good aspects of the health care experience. Perhaps part of the problem is that there is not enough to differentiate basic healthcare providers. Or is it more accurate to state that the current delivery system does not require providers to differentiate? Some of this is related to education and some to consumer awareness and of course expectations.

I have to admit that this comes from a career-marketing guy, who is always amazed at the ultimate power of the consumer. However, in health care, the consumer is still asleep, but the wakeup call seems to be approaching.

Health care is an amazingly challenging topic.

Manu Varma said...

This may be an identical but simpified version of Dr. Poses's comment, but I'd be happy to limit heroic measures during the last 30 days of life if we knew when those last 30 days were!

My view comes (as usual) from the world of organ transplantation, where patients may be facing a near-certain death without a organ but enjoy good-to-excellent survival rates after transplant. In such tight timelines, organ availability is completely unpredicatable. So a patient may be treated in an ICU at great expense, which could either end up supporting a miracle if they get a transplant or wasteful and painful if they don't. It may not be all or nothing, but it's pretty close...

Finally, I'd like to ask or hear what measures Beth Israel Deaconess takes to limit unnecessary care at the end of life while providing cutting-edge treatment for critically ill patients...and how you balance these two goals.

Manu Varma said...

For a vivid illustration of the above dilemma, there's the story of a high school student named William who developed acute liver failure, needed an emergency transplant, received it within days, and returned to an active life (surfing, guitar). Just five months later, he developed sudden complications of his transplant and was listed for a second transplant, which did not come in time to save his life, and he died. I can only imagine how high the costs ran for this treatment, but was it wasted the first time? The second time? My answer is "neither"

I'm not sure if pointing out this site is appropriate or too personal, so please feel free to delete this comment. It's on MySpace and completely public, but it is a very personal story.

Elliott said...

Universal access is the key. We will either bankrupt ourselves or learn how to rationally allocate reources.

Anonymous said...

Long ago, when a young girl I knew died of lymphoma at the age of 13 at MSK, her mother was asked why she put her daughter through the agony of 18 months of treatments and hospitalizations when the outcome was known at the beginning. She obviously treasured those 18 months and knew the price that she paid was to permit MSK to "learn" what they could about the disease from the way it progressed in her daughter. Is there something in that when it comes to end-of-life care? Or is it merely warehousing?

Christian Sinclair said...

Both Dr. Poses and Manu Varma touch on the point that I think underlies most of the dilemma in health care, which is predicting the future. The media and those in hospice & palliative medicine (like me) often quote high medicare expenditures in the last year of life. But no one ever teaches physicians how to formulate a evidence based prognosis. The literature lacks great breadth or depth on prognosis as well.

If you search PUBMED for the three core clinical skills of a doctor this is what you get:

Diagnosis: 5.6 mil articles
Treatment: 5.3 mil articles
Prognosis: 600k articles

Prognosis as a skill has not been supported in research or education and if we want to use technology and treatments in the appropriate manner for the greatest individual good and societal good, we need to be better at prognostication of various health outcomes.

In addition, despite their many flaws, advanced directives, and living wills should be 'REQUIRED' before any surgery, chemo, radiation therapy, hospitalization and upon discharge.

If we did that and have a national or state databases for advanced directives, we could be on the way to solving may problems. And I am fine if someone wants to say they want very aggressive care in their advanced directive, not just comfort care language.

And thanks for your blog Paul.

If anybody is more interested in evidence based end of life care, check out Pallimed

Anonymous said...

Lots of great comments. Thank you.

Let me just pickup on Elliott's:
"Universal access is the key. We will either bankrupt ourselves or learn how to rationally allocate resources."

I talk with lots of people from other countries that have a national health system that provides universal access, and not one has suggested that the rationing system in place is any more logical than the free market system that exists here. In some countries, a system of private insurance has arisen in parallel to the government health service to provide "extra" services to those who can afford it. In some countries, people leave and fly to the US or elsewhere to get access to advanced therapies that they cannot get at home through their government-provided system. In some cases, people wait for hospital services because the national health system has spent through its operating budget before the end of the fiscal year.

I don't suggest our system is at all perfect, but there are problems with the others' as well. To expect rationality in a system dominated by the appropriations of the legislature is to ignore centuries of public policy decisions in other arenas. Unless, of course, you mean that a majority vote by definition is to be equated with rationality.

Elliott said...

Ah, but they spend less money in the other countries and get just as good as results.

Let's say you had an important non-healthcare decision to make. One method proposed would be to hire an expensive consultant and another method to flip a coin. Let's say that all available evidence showed that people who flipped coins made decisions just as good as those who hired expensive consultants. What would you do?

Anonymous said...

Get a different coin?

No seriously, an interesting question, but I don't understand what it has to do with the point at hand?

Anonymous said...

I might have been more clear in my question about end of life care. Do physicians and researchers have an incentive other than financial to keep patients alive because they learn something about disease, prognosis, effectiveness of treatment, etc.?

Anonymous said...

I don't know any physicians who would keep someone alive for that purpose. The wishes of the patient and family come first.

Others should certainly comment.

Elliott said...

Your response to my statement about universal access was that these other countries had their own problems. My response is I don't believe that they are messed up as us, but even if they are, spending less money and getting the same result is pareto optimal. The coin flip situation is an example of that where business professionals often fail (load fees form mutual funds). In the US we have multiple instances of this type of failure in healthcare where we spend more money for the same or worse result. Sorry for not communicating my response more clearly.

P.S. I see no proof that other countries rationing decisions are sub-optimal relative to ours or more political. In fact, I challenge you to find hard data on that. I think you're talking to a biased sample of people when you reach that conclusion. I can think of multiple political decisions in this country. (HPV vaccine, spinal fusion reimbursement, no Medicare drug price negotiation, residency funding, etc.)

Anonymous said...

don't worry your hospital is doing cost containment like that right now, today.

Roy M. Poses MD said...

Re: the discussion of physicians' prognostic judgments raised by Dr Sinclair above.

Most of my academic career, before I got interested, some would say obsessed with ethical issues and problems with health care leadership, I studied how physicians make diagnostic and prognostic judgments, why they have trouble making them, and how to help them make them better. My theoretical underpinnings came from judgment and decision psychology.

I was not the only person working in this field, and collectively we do know something about what the problems are, and maybe even what some solutions might be.

However, this field of study made a lot of physicians uncomfortable, not unexpectedly. Worse, it attracted little funding, and as funding has become ever more important in academic medicine (see:, therefore attracted little interest.

I'd be happy to talk off-line to anyone who is further interested in these issues, and supply some references.

Anonymous said...


My sample is admitedly small and unscientific, mainly people I have talked to from other countries or who have studied them.

Unknown said...

As a palliative care nurse I agree with much of what has been said. To me the most important thing is direct and full communication with patient/family before something happens. It's not enough to get an advanced directive just to have one. We need to encourage family dialogue before the patient ends up on a ventilator in ICU and the doctor asks the family if they want him to do "everything".

Any surgeon CAN put in a AICD in a 95 yo demented patient, along with trach and PEG, but WHY? Instead of simply talking with the families, and maybe showing them the suffering, we spend 30 seconds and ask if they want everything done.

Most of the time, when I am allowed to consult on these issues, educating the family helps them to see that the care their loved one is receiving is not good care. Oh, technically it is excellent care, but it is not good. As we all know, when a family allows suffering to continue, there is almost always a reason they're not letting go. Addressing these spiritual, emotional and social issues can help the patient and family achieve peace, rather than prolong the suffering.