The Dartmouth Atlas Study: EM’s Bitter Pill

According to the Dartmouth Atlas of Health Care, care for people with chronic disease now accounts for more than 75% of ALL health care spending. One third of Medicare spending each year is spent on patients with chronic diseases who are in the last two years of their lives. And most of these patients have CHF, chronic lung disease, or cancer. Moreover, if Medicare spending is not reined in, it is expected to double over the next decade, reaching $4 trillion by 2017. 

 

According to the Dartmouth Atlas of Health Care, care for people with chronic disease now accounts for more than 75% of ALL health care spending. One third of Medicare spending each year is spent on patients with chronic diseases who are in the last two years of their lives. And most of these patients have CHF, chronic lung disease, or cancer. Moreover, if Medicare spending is not reined in, it is expected to double over the next decade, reaching $4 trillion by 2017.

But the real problem, according to the authors, is not the volume of spending, but the gross disparity between the money spent on the same diagnosis in different locales. For instance, an elderly person in Bend, Oregon spent on average 10.6 days in the hospital in the last two years of their lives while a person in Manhattan spent 34.9 days. The variation was even more striking in the last six months of life. Chronically ill patients in Ogden, Utah visited their doctors an average of 14.5 times while someone with the same diagnosis in LA saw their doctor 59.2 times over the same period.

The result is that Medicare spends a lot more in some parts of the country than others for the same or worse results. The most expensive state in the union for Medicare is New Jersey, spending 25% more than the national average.

The problem, according to these authors, is not the cost of each service, but how many services that doctors prescribe. In other words, the culprit is the doctor who admits a patient and then consults a horde of specialists. This kind of care tends to be chaotic and inefficient says Shannon Brownlee, author of Overtreated: Why Too Much Medicine is Making US Sicker and Poorer. And it doesn’t matter how you pay for care, public or private, all the countries of the developed world have the same problem. We all see examples of how specialists can put blinders on and not see the whole patient. But the medical profession as a whole has been slow to admit that more care is not always better care. Brownlee says that we have ignored the obvious because it “implied a transgression of professionalism.” But the evidence is mounting that medicine is inefficient, and it may be time for the medical profession to stop denying and start looking for answers.

The key to improvement, according to the Dartmouth Group, lies in emulating the systems that are efficient. The group claims that if Medicare was benchmarked to the efficiency of the Mayo Clinic, the nation would save $50 billion over four years in Medicare expenditures alone. Brownlee claims that the key to proper incentives is to dismantle the fee-for-services system that rewards doctors for doing more tests and treatments. The best alternative, she claims, is “the ‘c’ word: capitation,” where primary care physicians are salaried, with incentives for efficiency and they control access to specialists. “I’m a strong supporter of the ‘medical home’ concept,” says Brownlee. But so far patients have not been so accepting of this concept. A similar concept was tried 20 years ago by HMOs and they ran into tremendous resistance from patients, who, it seems, want to be able to go to a specialist without obtaining approval from their primary care doctor.

How much does the fear of litigation drive the over-utilization by doctors? It’s significant, says Brownlee, but its impact on the total amount spent is not as much as one might think. When The Dartmouth Group studied hospitals in close proximity to each other, each impacted equally by regional malpractice, there were still large variations in utilization. According to this finding, Brownlee claims that caps on awards and other current proposals for tort reform will have little impact the overall utilization of medical services. But will decreasing utilization of tests and treatment result in more litigation when bad outcomes occur? No one seems to know.

And what about patient demand? Don’t patients drive the demand for over-utilization? Physicians know that patients demand antibiotics that they don’t need. Doctors also know families that demand hospitalization when we feel it is not necessary. Is the only answer to have a national medical board that gives national policy for who gets admitted and who doesn’t? Probably not, says Brownlee. But, she adds, “there are insufficient clinical guidelines for when to hospitalize patients. And it seems unfair to put all this on the backs of the ER docs.” So what is the emergency physician to do? Some of it starts with clearer communication. But that, as with so many things, is easier said than done. Explaining to a family member that their elderly parent is not likely to benefit from being in the hospital, and may even do worse is a hard sell at best. And it’s not likely to go over well with hospital administration either.

The bottom line of this line of thinking is a new look at the previously unthinkable: rationing. Build fewer hospital beds. Build clinical guidelines that say when a chronically ill patient may be admitted and what services should be provided. And when they are discharged, how many visits to their doctor are allowed. This is a bitter pill and is not likely to go down well with the enlarging population of older and chronically ill patients. But is it the only way to rein in costs?