More Does Not Mean Better: Chronic Disease Care

The uneven distribution of health care costs is a vitally important aspect of the overall reform debate. Five chronic diseases account for 75% of our total national expenditures for health care across the board.

On Monday, the Dartmouth Atlas of Health Care put out a press release (via The Earth Times) about their newest study in which they focus on the part that Medicare plays in this aspect of the ongoing battle for health care reform. Evidently the amount paid by Medicare is highly variable, as is the treatment received:

"This report demonstrates the need to overhaul the ways we care for Americans with chronic illness," said Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation. "The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they or their families actually want or need."

The first image that came into my mind while reading this was that of an auto mechanic advising a complete engine overhaul to treat a set of failing spark plugs. More is not always better.

The new edition of the Dartmouth Atlas of Health Care: Tracking the Care of Patients with Severe Chronic Illness shows that institutions that give better care can do it at a lower cost because they don't over-treat patients. However, the Atlas documents that Medicare and most other payers encourage the over-use of acute-care hospital services and the proliferation of medical specialists thanks to misplaced financial incentives, especially for treating chronically ill people.

This is a serious problem. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. And over-use and overspending is not just a Medicare problem--the health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses.

Misplaced financial incentives, indeed. As George C. Halvorson has pointed out in his book, Health Care Reform Now!, there are over 9,000 billing codes for medical procedures, yet not a single one exists for a cure. The Dartmouth report supports the assertion that it is not the only the cost of care but also the sheer number of procedures prescribed, some necessary and some not, that is at the core of this aspect of the problem.

The Dartmouth Atlas Project studied the records of millions of Medicare enrollees who died from 2001 to 2005 and had at least one of nine severe chronic illnesses. Using those records, researchers benchmarked care nationally to the care provided in the region where Mayo has its flagship clinics and is far and away the dominant health care provider. Total spending for the population in this study was $289 billion over the five years. If the spending per patient everywhere mirrored that in Mayo's home region of Rochester, Minn., Medicare could have saved $50.1 billion, or 17.3 percent of all spending on these patients alone. A benchmark to a higher cost but efficient region such as Sacramento, Calif., where labor costs are the 26th highest of the 306 regions, shows Medicare would still have saved $28.9 billion.

The study paints a picture of a system in disarray over the treatment of these illnesses. There are no good, clear guidelines for when to hospitalize these patients, admit them to intensive care, refer them to medical specialists or--for most conditions--when to order diagnostic or imaging tests..

The numbers are both enlightening and disturbing. The wide variances from provider to provider point to a lack of consensus on proper course of treatment for these ailments as well as the lack of systems thinking in the industry, e.g., lack of across the board standards and measurements of performance.

The links below will take you to the full press release as well as to the Dartmouth Atlas of Health Care site where you can purchase or download the full report itself.

SOURCE:"Press Release: Chronically Ill Patients Get More Care, Less Quality, Says Latest Dartmouth Atlas" 04/07/08
SOURCE:"The Dartmouth Atlas of Health Care"
photo courtesy of Mel B., used under this Creative Commons license

One Third of Americans Call for Health System Rebuild While SCHIP Faces New Veto

Thursday the SCHIP legislation cleared the senate by a vote of 64-30, still not enough to override the promised veto from the executive branch. This would be President Bush's second veto of this legislation.

The Associated Press analysis of the situation yields the following:

In a situation of bewildering political complexity, Republicans dictated the decision to pass the legislation speedily. It appeared their goal was to short-circuit attempts by supporters of the bill to reach a compromise that could attract enough votes in the House to override Bush's veto.

Attempts by [U.S. Senator Harry] Reid to delay final passage of the bill until next week or longer drew objections from the Republicans.

This new round in the ongoing SCHIP battle comes as Science News brings us the results of a new seven nation study by the Commonwealth Fund, showing that over one third of Americans want a total rebuild of our health care system from the ground up. This is the highest rate of any of the countries surveyed, and cites medical errors, costs, and long waits for treatment as major contributing factors.

As in previous surveys, U.S. adults were most likely to have gone without care because of cost and to have high out-of-pocket costs. In the U.S., nearly two of five (37%) of all adults and 42% of those with chronic conditions had skipped medications, not seen a doctor when sick, or foregone recommended care in the past year because of costs -- rates well above all other countries. In contrast to the U.S., patients in Canada, the Netherlands, and the U.K. rarely report having to forgo needed medical care because of costs.

In addition, one-fifth of U.S. adults report serious problems paying medical bills--more than double the rate in the next highest country. And nearly one third (30%) in the U.S. spent more than $1,000 in the past year out-of-pocket -- a level rare in most of the other countries.

Some additional statistics provided from the report include:

• 1 in 5 report doctors advising treatment perceived as having little to no benefit


• Only in the Netherlands do people spend more time on paperwork and medical bill/insurance disputes


• The U.S. has the second highest percentage of adult visits to the emergency room (36%) out of nations surveyed, exceeded only by Canada.

SOURCE: "Congress Passes New Child Health Care Bill, Setting Up Another Veto Fight With Bush" 11/02/07
SOURCE: "One Third of U.S. Adults call For Completely Rebuilding Health Care System" 11/04/07
remixed photo courtesy of James and Vilija, used under this Creative Commons license