A Weblog of Centrist Voices in American Politics
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A Weblog of Centrist Voices in American Politics | |
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July 15, 2006More Care = Better Care?In a recent NYT op-ed Dr. David Goodman discussed the physician supply and its effects on elder care. Many studies have demonstrated that quality of care does not rise along with the number of doctors. Compare Miami and Minneapolis, for example. Miami has 40 percent more doctors per capita than Minneapolis has, and 50 percent more specialists...The elderly in Miami are subjected to more medical interventions — more echocardiograms and mechanical ventilation in their last six months of life, for example — than elderly patients in Minneapolis are. This also means more hospitalizations, more days in intensive care units, more visits to specialists and more diagnostic tests for the elderly in Miami. It certainly leads to many more doctors employed in Florida. But does this expensive additional medical activity benefit patients? Apparently not. The elderly in places like Miami do not live longer than those in cities like Minneapolis. According to the Medicare Current Beneficiary Survey, which polls some 12,000 elderly Americans about their health care three times a year, residents of regions with relatively large numbers of doctors are no more satisfied with their care than the elderly who live in places with fewer doctors.Dr. Goodman is part of an ongoing research project , The Dartmouth Atlas Project. The Project's focus has been on the relationship between health care utilization/spending and outcomes. The results tend to be very disconcerting for the Health Care system. For example, the conclusions of another recent study 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 Because I'm "inside" the system I hear this news loudly. I'm not sure how much press it gets in the "real world" but I beleive these finding will have profound and long-term efforts on how policy makers and health plans view the American Health Care (i.e. "Less for More) Posted by c3 at July 15, 2006 11:09 AMComments
Yeah, I posted on another study with similar results a few months ago. Same people, the Dartmouth Atlas Project. Might even be the same study. 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. IOW, there's no cost/benefit analysis being utilized, and no resulting prioritization of treatment. With the demand being patient-driven with no regard for cost or effectiveness, the results are predictable. Extreme over-utilization, to the point where 50% of Medicare expenditures were essentially wasted. Posted by: Tully at July 15, 2006 08:42 PMBlog in haste, wipe egg off of face at leisure. Should read "...to the point where a third of Medicare expenditures were essentially wasted..." A third waste meaning 50% more is being spent than need be for the same results. Posted by: Tully at July 15, 2006 09:26 PMAnd I would further suggest that the coming tidal wave of boomer retirement will inundate the system: because there are so many of us and because we want so much. Posted by: c3 at July 16, 2006 11:08 AMYou greedy bastards... ;) Posted by: PatHMV at July 16, 2006 04:41 PMGo ahead and try and pull my plug... Posted by: c3 at July 17, 2006 12:54 AMHow do you get people to accept "rationing" on the basis of such efficacy studies, without seeing a concurrent decrease in satisfaction? [Just using that term as quickie, not to start a fight. I'll cheerfully concede that rationing is, surprise surprise, a rational response to to controlling costs in this situation, and especially so when the cutbacks in the free supply can be made without, apparently, negatively impacting patient outcomes (leaving aside peace of mind...) Mind you, I'm not quarreling with what the study says. But I know that if you tell people "you only need this test once every 3 years instead of every year," people get miffed. Or if you tell them you'll only pay for 2 teeth cleanings per year even though your doctor says that you need 3, again, there's miffage. I'm wondering is a reform regime would be able to get through if you promised people savings _and_ allowed a limited number of appeals or automatic exemptions. Something where, if someone reall felt they needed the extra attention and the HMO or whatever wouldn't pay, you could have one or two automatic overrides per year, but if you were a chronic overconsumer of unnecessary tests, it would start coming out of your pocket after the first two or three, say. Posted by: bk at July 17, 2006 01:30 PMI think most over use is driven by physicians (no offense Chris) rather than patients. Given the risk of malpractice, I don't blame them for practicing defensive medicine, but my experience (obviously not related to Medicare)with one doctor is that he prescribed things for me (a colonoscopy at 45 with no family history of colon cancer, a heart screening) that really were not necessary and, in some cases, created more anxiety. I didn't mind it because I wasn't paying for it (well, I did mind the colonoscopy), but in retrospect, it was a waste of resources. My current doctor is much less inclined to go overboard--but I guess we will see if my health suffers for it, but so far it has not. Posted by: Marc at July 17, 2006 02:04 PM"Miffage." What a useful new term! I like it. All limited-quantity goods are rationed, always. Whenever demand exceeds supply, there IS rationing. We ration health care now. We ration by price. The problem being that the entire market is not subject to that price rationing. The elderly over-utilize as a class because they enjoy universal health insurance in the form of Medicare, and thus do not face the full tab for their health care. Instead, taxpayers as a whole pay it. Which is one reason so many non-elderly lack health insurance--they're paying out that money for Medicare, so it is not available for their own health care. In addition, that additional care cost gets distributed across the entire system, raising health insurance costs for those not in the "universal payment system" of Medicare. They are thus rationed into under-utilization or out of the market by price. Which in turn also raises prices, as the patients present as acute emergencies instead of having their conditions prevented or cured early by routine care. Care they skipped to keep eating. This will not change unless Medicare institutes some serious cost/benefit screening for payments purposes, or until we have universal health insurance in America. Even then, that just means the rationing will be spread across the board, instead of one group being unrationed at the cost of higher prices and greater market-cost rationing on everyone else. But if you spread it across the board, cost/benefit analysis is mandatory for fairness. Posted by: Tully at July 17, 2006 03:35 PMA few responses: I'm wondering is a reform regime would be able to get through if you promised people savings _and_ allowed a limited number of appealsMedicare members in and out of Managed Care have appeal rights (and they sure use them. I think most over use is driven by physicians (no offense Chris) rather than patients.Its driven by both (and no offense taken). That's why all the drug ads on the nightly news broadcasts (and the Discovery channel): elderly demographic. One key aspect about these studies. You'll note that one focus is utilization in the last year or last months of life. If you ask folks when they're well, what they want, they probably will answer differently (i.e. "I don't want aggresive care")than when the rubber hits the road ("your grandkids money or your life"). And often you don't get to ask the patient but have to ask the family. Unfortunately most family members are not good judges of what their loved one wants. So when in doubt...tube 'em, cut 'em and dialyse 'em. Posted by: c3 at July 17, 2006 09:11 PMIt's definitely both, not just one or the other. Part of that is the reluctance of doctors to quote odds to a patient or their family unless forced to, and sometimes not even then. They may know a long-shot desperation treatment has only 1 chance in 50 of any significant life extension, and that even the "win" sometimes comes at a cost of very degraded quality of life, but they don't want to come out and say it. Instead they go for the long shot. I certainly can't blame someone for that--I love life myself--but their decision might have been different had they known the odds and the cost. 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