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Less is more for the chronically ill

By Laura Stephenson Carter

Dartmouth's Center for the Evaluative Clinical Sciences (CECS) is at it again. Known for its Dartmouth Atlas of Health Care and study after study showing that more care does not necessarily yield better outcomes, CECS has now revealed startling variations in spending on chronically ill, elderly people. The study documented potential savings of $40 billion over four years if all U.S. hospitals followed practices used in Salt Lake City, Utah; Rochester, Minn.; and Portland, Ore.—cities where patients get high-quality, low-cost care. Patients there are admitted to hospitals less often, spend less time in intensive care units (ICUs), and see fewer specialists.

The variations in spending—according to researchers John Wennberg, M.D., M.P.H., and Elliott Fisher, M.D., M.P.H.—are due to an unmanaged supply of resources, limited evidence about what care is best for the chronically ill, overdependence on acute-care hospitals, and overoptimism about the benefits of more aggressive treatment. In fact, chronically ill people can be cared for better and less expensively in home-health and hospice-care settings.

Claims: The researchers based their findings on Medicare claims data from more than 4,300 hospitals in 306 regions. They examined the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses, including cancer, congestive heart failure, and/or chronic lung disease. Average Medicare spending during the last two years of life for these patients ranged from about $24,000 in Idaho to nearly $40,000 in New Jersey. And during their last six months of life, average hospital stays ranged from seven days (Utah) to about 16 (Hawaii, New York, and others); ICU stays from fewer than two days (New Hampshire, Vermont, and others) to almost five (Florida and New Jersey); and physician visits from fewer than 20 (Vermont, Mountain States, and the Pacific Northwest) to more than 40 (New Jersey). Patients in high-spending regions had slightly shorter life expectancies and less satisfaction with their care than those in areas with lower rates of spending.

The report, funded by the Robert Wood Johnson Foundation, calls for an overhaul of the way chronic illness is managed and for a reimbursement system that rewards, rather than penalizes, organizations that reduce excessive use of services.

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