The More You Pay, the Better the Care? Think Twice

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The More You Pay, the Better the Care? Think Twice

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By EDUARDO PORTER

Published: December 17, 2006

http://www.nytimes.com/2006/12/17/business/yourmoney/17view.html?

_r=1 & oref=slogin

Costs and Benefits EXPERTS have long been puzzled by the existence

of large regional disparities in medical care in the United States.

Even for diseases for which the appropriate treatment is widely

accepted, doctors across the country take vastly different

approaches, often leading to enormous expense without making any

appreciable improvement in their patients' health.

Consider heart attacks. Prescribing beta blockers immediately after

a heart attack is a well-established, cheap and efficient treatment.

In Iowa, nearly 80 percent of victims in 2000 received the drugs

within 24 hours of a heart attack. In Alabama or Georgia, by

contrast, fewer than 6 out of 10 patients received the drugs.

" What makes the lag in beta-blocker adoption puzzling is that the

clinical benefits have been understood for years, " wrote S.

Skinner and O. Staiger, economists at Dartmouth, in a recent

study about these regional patterns.

Congress has decided that some treatment decisions may be best taken

out of doctors' hands. In one of their last acts this year before

adjourning, lawmakers passed a bill entitling doctors to a bonus

from Medicare if they report data on the quality of their care,

using criteria like whether they prescribe aspirin or beta blockers

to heart attack victims. In the future, this data would permit

Medicare to reward doctors who followed government guidelines.

Many doctors criticized the decision, saying it would impose a form

of medicine by cookbook that could endanger patients. Still, some

experts contend that this form of accountability is a necessary step

to deal with inefficiencies that riddle the health care system and

fuel much unnecessary spending on care.

Several new studies suggest that there is no relationship between

the amount spent on treating a patient and the quality and outcome

of the care.

Consider chronically ill elderly patients in the last two years of

their lives. According to a comparison of hospitals across the

country done by researchers at Dartmouth, if the patients die in a

hospital in New York State, the average cost of those two years

would be $38,369. In Florida, by contrast, it would be $29,604,

while in Iowa it would be only $23,746.

To be sure, much spending on health care provides enormous benefits.

A study published this year by Mr. Skinner, Mr. Staiger and Dr.

Elliott S. Fisher of Dartmouth Medical School found that Medicare

spending on hospital care for heart attack victims surged two-thirds

from 1986 to 1996, after accounting for inflation. But the

percentage of victims who were alive a year after their attacks also

increased, though by just 10 percentage points, to roughly 68

percent.

The relationship — rising costs bringing increased benefits — has

broken down recently. From 1996 to 2002, Medicare spending on

treatments for heart attack victims increased about 14 percent,

after inflation. But there was virtually no improvement in survival

rates.

There is mounting evidence that the zeal to treat and spend may

actually hurt patients. The study by Mr. Skinner, Mr. Staiger and

Dr. Fisher found that hospitals in regions where spending grew

fastest from 1986 to 2002 had some of the worst practices, in terms

of providing tried-and-true therapies, and recorded the smallest

gains in survival rates.

Treatment of heart disease underscores the deeply idiosyncratic

nature of many choices made by America's doctors and hospitals.

Coupled with a fee-for-service system that encourages aggressive

treatment, these choices stimulate health spending that provides

little benefit to patients. " A lot of the innovation and spending

growth are going into gray areas that are not helping people that

much, " Mr. Skinner said.

But perhaps the most puzzling inefficiency in how doctors treat

heart disease is not the spending on fancy yet ineffective

therapies. It's the lack of spending on treatments that have been

known to work for years, like beta blockers.

" The biggest failure of the American health care system is not that

we overuse stuff but that we underuse stuff, " said Cutler, an

economist at Harvard. Consider aspirin. It helps prevent formation

of blood clots, and its widespread use has probably been the

cheapest breakthrough in the history of heart disease treatment.

A study five years ago by Dr. Mark McClellan, who was to become the

commissioner of the Food and Drug Administration, and Dr. A.

Heidenreich of the Veterans Affairs Palo Alto Health Care System in

California, estimated that growing aspirin use explained more than a

third of the decrease in the death rates of heart attack victims

from 1975 to 1995.

Still, a Duke University study of about 32,000 patients with

coronary artery disease who were treated from 1995 to 2002 found

that only 83 percent took aspirin. And only 71 percent did so

consistently.

The financial incentives in the health care system are part of the

problem, experts say. These incentives encourage hospitals and

clinics to provide more services, hire more specialists and install

more devices. They shuttle patients from one specialist to the

other — providing more-scattered care. All too often, when the

patient leaves the hospital, nobody among the crowd of doctors takes

responsibility for prescribing the beta-blockers. " The system

rewards throughput and higher-margin services, " Dr. Fisher

said. " This leads us inadvertently to waste and inadvertently to

harm. "

He argued that hospitals and doctors must gather into bigger units

that coordinate care smoothly — sharing medical records and

responsibility for a patient's overall health. They should provide

information about treatments and outcomes. And, he said, Medicare

must start paying for results, measured in terms of lives improved

and extended and of value for the money.

Congress has taken a step in this direction. But changing entrenched

practices is not easy.

MR. SKINNER and Mr. Staiger found an odd pattern in the regional

propensities of doctors to prescribe beta blockers: it closely

matched the propensities of farmers to embrace hybrid corn early in

the 20th century.

Hybridization spread through Iowa's cornfields as early as the mid-

1930s. By contrast, in Alabama and Georgia it didn't take hold until

the late 1940s. In other words, the lag in the prescription of beta

blockers is not simply a problem of the health care system. It also

reflects regional attitudes about the adoption of new technologies,

the study concluded. That problem could take generations to solve.

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[Guest guest]

There are several drivers behind the push to computerize and share your

medical records, and unfortunately they aren't so much improving care as

reducing the costs to businesses that pay for most of our medical care in

this country.

Right now it would be a huge mistake... Medical IT is incompatible with our

system of private insurance because private insurers will use it to

disqualify people from receiving insurance coverage.

So right now, it would be used to deny care to people who needed it.