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The State of the Nation's Health

The U.S. spends more on health care than any other nation. Does that money buy what it should? Not according to decades of Dartmouth research on regional variations in spending and outcomes. But policy-makers are now paying attention to the DMS work—and therein may lie a solution to the money-medicine puzzle.

By Maggie Mahar

These are a few of the headlines that research from Dartmouth's Center for the Evaluative Clinical Sciences (CECS) generated last year—a clear sign that its message is beginning to reach a wider public, just in time to become part of the nation's renewed discussion about health-care reform. That message can be distilled to a single sentence: "More care does not mean better care."

For decades, Americans have assumed that the fact that we spend so much more on health care than any other country stands as proof that we have the best health-care system in the world. But over the past 20 years, work done by Dartmouth's Dr. John Wennberg and Dr. Elliott Fisher has forced U.S. health-care leaders to acknowledge that this simply isn't true.

Investigating staggering differences in how much Medicare spends on patients in various parts of the country, the Dartmouth team has discovered that in Manhattan and Miami, chronically ill Medicare patients receive far more aggressive care than very similar patients in places like Salt Lake City, Utah, and Rochester, Minn. Their research reveals that Medicare beneficiaries in high-cost states are likely to spend twice as many days in the hospital as patients in low-cost states and are far more likely to die in an intensive care unit. The

Dartmouth's Elliott Fisher, left, and Jack Wennberg, right, have put Dartmouth on the map with their health-utilization research.

odds are higher that patients in high-spending regions will see 10 or more specialists during their final six months of life. These facts alone aren't terribly surprising. But here's the stunner: Chronically ill patients who receive the most intensive, aggressive, and expensive treatments fare no better than those who receive more conservative care. In fact, their outcomes are often worse.

In high-cost regions, "patients with the same disease have higher mortality rates, very likely because of medical errors associated with increased use of acute-care hospitals," Wennberg and colleagues noted in a 2006 study of patients suffering from chronic diseases like cancer or congestive heart failure. As Fisher puts it, "Hospitals can be dangerous places—especially if you don't need to be there."

Thirty years of research
When CECS founder Jack Wennberg began publishing his research some 30 years ago, the medical establishment did not welcome his input. After all, one person's overtreatment is another's income stream. When people who have known Wennberg for a long time talk about him, they often use the word "courage."

"In the 1980s, people tried to poke holes in the data—to say that patients are different in different parts of the country," recalls Glenn Hackbarth, chair of the Medicare Payment Advisory Commission (MedPAC), an independent body charged with making recommendations to Congress.

But of course Dartmouth's researchers had considered the possibility that patients in some regions of the country might simply be sicker. So, over the decades, they have bent over backwards to adjust for differences in race, age, sex, and the overall health status of each community.

They acknowledge, for instance, that salubrious conditions in Grand Junction, Colo., mean that per capita Medicare outlays there will probably be about 20% below the national average, and they make an adjustment for that fact. By contrast, the comparatively poor health of Medicare beneficiaries in Birmingham, Ala. (one of the nation's least healthy communities), suggests that spending there should be nearly 25% above the national average. Nevertheless, even after factoring in these differences, Medicare expenditures are still twice as high in some regions as in others.

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Maggie Mahar is a Manhattan-based journalist who has worked for the New York Times, Bloomberg, and Barron's. She has also written for Money magazine and Institutional Investor and is the author of two books—Money-Driven Medicine: The Real Reason Health Care Costs So Much (published in 2006 by HarperCollins) and Bull! A History of the Boom and Bust, 1982-2004 (published in 2003 by HarperCollins and recommended by Warren Buffet in Berkshire Hathaway's annual report). Before becoming a journalist, Mahar taught English literature at Yale. This is her first article for Dartmouth Medicine.

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