David C. Goodman, MD
David C. Goodman, MD, professor of pediatrics and of community and family medicine, Dartmouth Medical School, Hanover, New Hampshire.
More than 90 million Americans suffer from chronic illnesses such as cardiovascular disease, diabetes and cancer… and 32% of Medicare spending was dedicated to end-of-life-care for patients with these chronic conditions between 2001 and 2005. Yet a recent report at Dartmouth Medical School uncovered startling regional variations in the intensity and cost of this care. Their findings: Though in some regions of the country older patients get more costly and aggressive care than in others, there is generally no difference in mortality and in some cases patients even die slightly sooner.
In The Dartmouth Atlas of Health Care 2008, researchers analyzed records of elderly Medicare beneficiaries who died from common chronic diseases — congestive heart failure, lung disease, coronary artery and circulatory disease, cancer, dementia, diabetes and kidney or liver disease. Collectively, these chronic ailments are responsible for the deaths of 90% of people 65 and over.
How these individuals were cared for in their last months of life varied widely across the country, researchers discovered. Care ranged from conservative (fewer doctor visits, fewer days in the hospital and fewer days in intensive care, and a greater emphasis on primary care) to aggressive measures (more doctor visits, more days in the hospital and in intensive care, and more consultations with specialists). Not surprisingly, there were corresponding differences in cost, with Medicare expenditures reflecting startling regional differences. The average Medicare cost per patient in the last 24 months of life ranged from over $57,000 in Manhattan to $15,000 in Dubuque, Iowa. Only a third of this is due to difference in price. The other two-thirds reflect differences in the intensity of care.
This isn’t just about care provided to the elderly at the end of their lives, either. According to coauthor David C. Goodman, MD, a professor of pediatrics and of community and family medicine at Dartmouth Medical School, patients of all ages can generally expect more aggressive treatment in regions with higher bed supply and more physicians. Critical to realize, however, is that more care doesn’t translate to better results.
The Dartmouth researchers found the discrepancies may have more to do with available resources than diagnosis. In areas where there are lots of doctors and hospitals and high-tech healthcare is widely available, patients get more aggressive care.
In areas with high intensity of care and high costs, patients spent on average 22 days in the hospital and made 60 visits to physicians in their final six months, contrasted with low-cost areas, where the averages were six days in the hospital and 15 doctor visits. While aggressive care provides more services for patients — more diagnostic tests and more procedures, more visits to specialists, longer hospital stays and longer periods in intensive care — all of the patients in the Dartmouth report had the same outcome (death). In other studies, the Dartmouth team has shown that higher regional intensity of care for patients with hip fracture, heart attacks or colorectal cancer (all of which require hospitalization but are not necessarily fatal) is associated with little difference in outcomes, and in some cases even a slightly higher death rate.
Problems arise as more hospitalizations expose people to more hospital-acquired infections and medical errors. The risk of harm can multiply when many doctors care for a patient, especially without careful coordination. Also, more diagnostic tests can find “abnormalities” that turn out to be harmless after many more tests, some of them with their own risks.
According to Dr. Goodman, the remedy to this “needless variability in care and cost” is for the medical profession to develop and institute evidence-based guidelines on best practices. He believes reimbursement for care should reward better outcomes, not just higher volume of services. Until these reforms are in place, concerned healthcare consumers can take these steps to increase the odds of getting the best medical care…
The high cost of medical equipment and the need for doctors to protect themselves from lawsuit provide motivating factors to prescribe treatments beyond patient wellness. In the end, medicine is a business and more care often means greater profits for healthcare providers, from the physician to the hospital to the drug and device manufacturers. Be sure that what your doctor is recommending is truly in your best interest.