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Costly care isn't better care

By Jennifer Durgin

"It's worth it" has been the prevailing assumption about the rising costs of treating acute myocardial infarctions (AMIs)—heart attacks. For every 100 elderly heart attack patients, 10 more survived in 2002 than in 1986, thanks to various technological and treatment advances. And every year of life saved cost less than $25,000, explained three DMS researchers in a recent issue of Health Affairs. "But"—and this is a big "but"—"underlying these numbers is tremendous heterogeneity across time and space," they wrote.

By analyzing Medicare claims data from the nation's 306 hospital referral regions, they found that areas that spent the most on AMI treatment had the lowest gains in survival between 1986 and 2002. Furthermore, improvement in heart attack survival rates stagnated after 1996, though the cost of treatment has continued to grow. The researchers also found that survival gains were lowest in regions where there were more physicians treating each AMI patient.

This message—that spending more doesn't necessarily improve care—has been reinforced time and again by researchers at DMS's Center for the Evaluative Clinical Sciences. CECS physician-researcher Elliot Fisher, M.D., a coauthor of the AMI study, has shown in previous studies that Medicare patients in high-spending regions have neither better outcomes nor more access or satisfaction. But it was unclear until now if this held true in heart attack care, where there have been numerous (costly) technological innovations.

Measures: "On average, everyone is better off," wrote Fisher and his coauthors—Dartmouth health-care economists Jonathan Skinner and Douglas Staiger—"but the regional gains are not correlated with regional spending increases." The team was careful to note that their study did not evaluate the effectiveness or benefit of high-tech, highcost treatments. Rather, their findings point to the need to develop "measures of quality and efficiency that can encourage [providers] to adopt low-cost, highly effective care, while discouraging incremental spending with no apparent benefits."

"Put more simply," they noted, "the benefits of health spending depend on how one spends the money."

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