The State of the Nation's Health
Nor do patients appear to appreciate all of the attention. "We have some preliminary data about patient reports on quality, mostly from California," Fisher told the commission, "and patients in the higher-cost systems seem to report less satisfaction with care." Doctors in high-treatment areas appear equally unhappy. "We now have had an opportunity to interview doctors across the country," Fisher said in his MedPAC testimony, "and when physicians describe the quality of care, those in the higher- spending regions say that quality is worse."
What is most startling is that even at the nation's most prestigious academic medical centers, supply seems to drive medical decision-making. Since teaching hospitals are seen as setting the standard for best practices nationwide, one would assume that at these facilities, treatment rates would not vary much from one part of the country to another. One would be wrong.
For example, Dartmouth's researchers compared patients at different academic medical centers six months after a hip fracture. They discovered that patients at teaching hospitals in high-spending regions were the recipients of 82% more physician visits, 26% more imaging exams, 90% more diagnostic tests, and 46% more minor surgeries—without noticeable benefit.
In another study, researchers zeroed in on how hospitals in California care for the chronically ill during their final two years of life. They found that Medicare paid some hospitals four times more than others—with no gain in the quality of care or patient satisfaction. Meanwhile, the two-year tab for similar patients ranged from less than $20,000 to more than $90,000, with the number of days that patients spent in the hospital accounting for roughly two-thirds of the difference.
What is driving the more aggressive care for chronically ill patients in cities like Los Angeles and Miami is "more hospital beds per capita, more medical specialists, and more internists." Yet with all of these resources, the outcomes are no better.
Among academic medical centers, the University of California-Los Angeles (UCLA) and the University of California- San Francisco (UCSF) stood out, with UCLA's patients spending 45% more days in acute-care hospitals than UCSF's and getting 37% more referrals to 10 or more different physicians.
Some hospitals claim that they provide more services because that's what consumers in their area want. But the truth is that few patients cry out for the opportunity to die in an ICU. Indeed, during their final two years of life, most would prefer to spend their days at home.
"People don't just go out and get care—their providers are telling them that they need care," points out consumer advocate Debra Ness, president of the
National Partnership for Women and Families. "This is not about consumer demand for the most aggressive care," she continues. "The 'more is better' mindset begins with the healthcare provider—not the consumer—because all of the financial incentives point providers in that direction."
Can waste help fund reform?
With its decades of data, Dartmouth has exposed the incredible waste in the U.S. health-care system. Sizing up the evidence, Wennberg estimates that up to one-third of the over $2 trillion that we now spend annually on health care is squandered on unnecessary hospitalizations; unneeded and often redundant tests; unproven treatments; over-priced, cutting-edge drugs; devices no better than the lessexpensive products they replaced; and end-of-life care that brings neither comfort nor cure.
As Dartmouth's 2006 paper, "The Care of Patients with Severe Chronic Illnesses," points out, if this waste were eliminated, "the Medicare system could reduce spending by at least 30% while improving the medical care of the most severely ill Americans" (emphasis added).
In resource-heavy, high-spending regions, Medicare spends 61% more keeping all those hospitals beds full and all those specialists busy. (And the researchers adjusted for price differences in different communities; it was sheer volume of services that accounted for the 61% difference.) Yet the money does not buy "a longer life, or better quality of life." On the contrary, the study reveals that mortality rates at academic medical centers in high-cost regions were 5.2% higher for colon cancer patients, 5.2% higher for heart attack patients, and 1.9% higher for patients with a fractured hip.
"This is a frightening finding—with