Researchers say more care is not always better
Process of care may play a part
Studies have shown that people in medically underserved areas with limited access to advanced technologies and specialists are more likely to have higher rates of serious disease and poorer health outcomes than those in areas without shortages. So it should stand to reason that the more providers and resources a region has, the healthier the population will be. Right?
Not exactly, say researchers at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School in Hanover, NH.
Utilization rates for expensive health services, such as surgical procedures, specialist visits, and intensive care stays, vary widely from region to region in this country without a significant difference in mortality rates or medical complications among patients living in different areas.
At some point, more doctors and hospitals simply leads to more treatments, not necessarily improved health, says John E. Wennberg, MD, MPH, the director of the center, which gathers epidemiologists, economists, clinicians, statisticians and sociologists to research how health care is provided across the country.
"If you have a lot of antique stores in a particular area, you don’t see people just buying more and more antiques. You may have some of the stores have a difficult time remaining in business," he explains. "But, with health care, the more providers you have, the more services are performed."
The question is: At what point are all the extra services squandered at the expense of needed care that isn’t available?
In the March issue of the policy journal Health Affairs, Wennberg and colleagues present the results of their study of Medicare expenditures nationwide for a variety of health services.1
Their findings document that Medicare spending varies widely according to where seniors live, even after correcting for differences in age, sex, race, pricing differences, and health status. For example, the difference in lifetime Medicare spending between typical 65-year-olds in Miami and Minneapolis is more than $50,000. In 1996, the annual bill for traditional fee-for-service Medicare in Miami was $8,414 — more than twice the $3,341 spent in Minneapolis.
But seniors in Miami are not in significantly better health or getting better treatments than their northern counterparts.
The variation in spending and resources is not just confined to older patients, however.
Neonatal intensive care disparities
A separate study, also performed by researchers at the Dartmouth center but published in May in the New England Journal of Medicine,2 confirms that more neonatalogists and more neonatal intensive care beds do not significantly lower infant mortality rates.
A survey of 100% of the neonatal intensive care units in the country revealed a wide disparity in availability of neonatal specialists and intensive care nursery beds. But there was no consistent correlation between the number of NICU beds and infant mortality.
In areas where there were fewer than 4.3 neonatalogists per 10,000 births, there was a difference in mortality rates (7% lower in regions with at least 4.3 neonatalogists/10,000 births than areas with 2.7 neonatalogists/10,000 births). But as the number of neonatalogists increase — more than 80% of the regions in this country have at least 4.3 specialists per 10,000 births — there was evidence of an increased benefit.
"We all know that infant mortality rates have declined, but they are still higher than rates in other developed countries. Yet, we have a really fantastic system of neonatal intensive care," says David C. Goodman, MD, lead author of the neonatal study and an associate professor of pediatrics at Dartmouth.
More research is needed to determine why this is so and what needs to be done to lower infant mortality rates, he adds. "There is still a question of whether the most efficient way of improving mortality would be to simply add more neonatalogists [in the area with the lowest number]. Is it because there are fewer specialists? Or is it a matter of other personnel, or because patient safety suffers? Or is it the unavailability of resuscitation in delivery rooms — so it is actually a delay of initial care? We need to understand the processes of care in more detail."
Neonatal intensive care is a clinical service that continues to grow, but the question this study raises is in what ways should the health system be encouraging the specialty to expand.
The current information indicates that promoting the growth of new units, more beds, and more neonatalogists is not the answer.
"There are many other possible avenues for improving outcomes — such as improving the science of caring for babies, improving the quality of care within existing units, or by preventing low birth weights," Goodman says.
Demonstration project proposed
As part of the study on Medicare expenditures, Wennberg and his fellow researchers recommend that health care organizations in areas of low expenditures be paired with those in high-utilization regions in demonstration projects that will determine appropriate levels of care.
According to Wennberg, the projects need to remedy the following major problems:
• Health care organizations serving fee-for-service Medicare patients lack the infrastructure to provide needed preventive medical services. There is a systematic underuse of these services, such as screening of colon cancer or prescribing the appropriate drugs for heart attack patients. For example, among the patients who should receive beta-blockers according to national guidelines, those who actually receive the drug vary from 5% to 92% across the country.
• There is a lack of patient involvement in medical decisions — particularly about elective surgeries. In theory, if there are alternative treatment options, physicians should give patients all of the relevant information and the patient should make the decision. But surgical rates vary by five-or tenfold from region to region, which indicates the choice is usually the underlying preference of the physicians in the region rather than the individual patients’ choices, says Wennberg. "That is well articulated and documented in many papers that we have done over the years."
• The frequency of use of everyday care, such as physician visits, diagnostic testing, and hospitalizations varies significantly among regions. While frequency of use of these supply-sensitive services explains the variation in Medicare spending, it is increasingly clear that more care does not equal healthier patients.
The current Medicare fee-for-service structure provides incentives for hospitals and physicians to provide expensive procedures, but not for less expensive services such as care coordination and preventive screenings, Wennberg adds.
The demonstration projects would help the system determine how to better allocate expenditures to achieve better outcomes.
"The participants would come back to the Centers for Medicare & Medicaid Services with proposed changes in the fee structure that would reward quality of care," he says. "You could look at the data and say, Well, hospitals overutilize.’ But if you then just cut reimbursements, then the facilities can’t take that money and reinvest in other things."
References
1. Wennberg JE, Fisher ES, Skinner JS. Geography and the debate over Medicare reform. Health Affairs Feb. 13, 2002.
2. Goodman DC, Fisher ES, Little GA, et al. The relation between the availability of neonatal intensive care and neonatal mortality. N Engl J Med 2002; 346:1,538-1,544.
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