Florida's high medical spending buys worse results, study says

By Susan Jaffe
4/7/2008 © Florida Health News

More definitely isn’t better when it comes to medical treatment, according to a groundbreaking study that compares treatment of Medicare patients across the country.

In fact, say authors of the Dartmouth Atlas of Health Care 2008, too much treatment not only wastes money, but may lead to worse results. Researchers analyzed care and costs in the last two years of patients’ lives and concluded that, contrary to what most people believe, “your chances of dying increase in regions where the health care system delivers more care.”

And what determines how much treatment patients get? The supply of physicians and hospital beds. In areas that have too much of both, the authors say, more treatment is rendered whether it’s warranted or not.

The report shows that in some parts of Florida, there appears to be substantial overtreatment caused by excess capacity. When it comes to spending for doctor’s visits and other outpatient care, for example, the Ft. Lauderdale and Sarasota areas are the highest in the nation during the last two years of life.

For details, download at the following: The complete Dartmouth Atlas: http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf. The executive summary at: http://www.dartmouthatlas.org/atlases/2008_Atlas_Exec_Summ.pdf  (Contains links to the state-by-state reports.)

For total Medicare spending on patients in the last two years of life, some areas in Florida average $72,000 per patient while others spend about half as much. Only New York and California have higher spending and greater disparities.

The Atlas, released this morning, simply explodes many of the common assumptions about good health care. They include the common belief that the best places to seek treatment are urban areas with big-name medical systems providing expensive, high-tech care.

The study answers many questions, especially: If the United States spends twice as much on medical care as other industrialized countries, why do studies continue to find that the health outcomes are worse?

If the American public and policymakers pay attention to the study – and the timing is good, with the Presidential campaign featuring debates about the soaring cost of health insurance and the growing number of uninsured -- experts say it could have a far-reaching impact on how medicine is practiced in the United States, especially for the 44 million older and disabled Americans with Medicare.

Entitled “Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008,” the report was prepared by researchers at the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire, led by Dr. John E. Wennberg. They focused on thousands of Medicare patients throughout the U. S. from 2001 to 2005 who were treated for one or more of nine chronic diseases – including heart and lung disease, cancer, kidney failure and diabetes – during the last two years of their lives. The report takes a bird’s eye view of all types of services, provided in every possible setting -- hospitals, doctors’ offices, nursing homes, and in the patients’ homes, provided by hospice or home health agencies. Then researchers zeroed in on local data, comparing regional health care markets in every state.

Compared to other states, Florida has the third-largest variation in spending per patient during the last two years life. Hospitalization costs per patient in the Miami regional health market were twice as much as the Tallahassee area, the study says.

Medical treatment for people with chronic diseases is erratic, rarely coordinated and different from one city to another and even within the same hospital system, the report concluded. For example, Medicare patients at Mayo Clinic’s affiliate in Jacksonville, St. Luke’s Hospital, were given far more intensive treatment than those at other affiliates. Mayo’s home hospital, St. Mary’s in Rochester, Minn., received top scores for both efficiency and outcomes.

Here’s another example, this time using Hospital Corporation of America’s Florida facilities: If two HCA hospitals in Miami that were studied had been operated as efficiently as the company’s Capital Regional Medical Center in Tallahassee, Medicare would save $31 million a year, according to the report.

The HCA example and many others in the study overturn the common assumption about health care, that more treatment and frequent physician visits are better than less aggressive care. Patients at the two Miami hospitals received 91 percent more physician visits during the last six months of life, more days in the hospital and more days in intensive-care units, but the quality of care was worse, according to Medicare’s “Hospital Compare” ratings. Aggressive treatment forced both Medicare and patients to spend more.

Another common assumption that the study overturns: Regional differences in Medicare fees don’t account for the higher overall medical and hospital spending. It’s the greater number of procedures and admissions per patient that drives up costs, the researchers found.

The study’s conclusion -- that much of what is done for patients near the end of their lives is unnecessary, potentially harmful and a waste of money – doesn’t surprise Dr. Ann O’Malley, a senior researcher who specializes in preventive medicine at the Center for Studying Health System Change.

“As physicians we are uncomfortable with uncertainty, and as patients we want to do everything possible,” she said. “And that can be a combination of factors that end up delivering care that leaves patients less satisfied and with poorer outcomes.”

The current payment system, whether it’s Medicare or private insurance, “disproportionately rewards doing more medical procedures and tests than it does for primary care or coordinating care,” she said. “And so you get what you pay for.”

Nearly a third of Medicare spending is on patients in the last two years of life. But it’s not just about the money, said Dr. Robert Butler, a founding director of the National Institute of Aging and the geriatrics department at Mount Sinai School of Medicine.

“There’s too much fragmentation in care,” Butler said. “There’s no traffic cop” to make sure a patient doesn’t receive duplicative, unnecessary treatments or incompatible medicines. Doctors often tend to “do things because that’s what they were taught to do,” he said, instead of what’s best for the patient.

The study underscores the need for better trained doctors and for more primary care doctors, said Butler and O’Malley. Studies have shown that patients who depend more on specialists receive more expensive care, but not necessarily better care, and they are not more satisfied, said O’Malley.

Without changes in the health care system, the Dartmouth study concludes that the cost of health care will continue to soar and the quality will not improve.

Advocacy groups like AARP say that’s a job for Congress.

“We need to look at cost containment in the whole system and for all patients across the age spectrum,” said AARP spokesman Drew Nannis. “It’s not enough to ensure that Americans have access to health care. We have to control costs so that it is affordable to those who need it.” 

Florida Health News Washington correspondent Susan Jaffe can be reached at susanjaffe@earthlink.net.