Dartmouth Atlas - Major overhaul of health care required
The Dartmouth Atlas of Health Care
In the News
May 16, 2006
New Study Shows Need for a Major Overhaul of How United States Manages Chronic Illness
Staggering variations in how hospitals care for chronically ill elderly patients indicate serious problems with quality of care and point toward unnecessary spending by Medicare. Lower utilization of acute care hospitals and physician visits could actually lead to better results for patients and prolong the solvency of the Medicare program, according to a new study by the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School.
Three issues drive the differences in the cost and quality of care, according to principal investigator John E. Wennberg, M.D., M.P.H.
“Variation is the result of an unmanaged supply of resources, limited evidence about what kind of care really contributes to the health and longevity of the chronically ill, and falsely optimistic assumptions about the benefits of more aggressive treatment of people who are severely ill with medical conditions that must be managed but can’t be cured,” said Wennberg.
The Dartmouth Atlas Project studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. The study demonstrates that even within this limited patient population, Medicare could have realized substantial savings - $40 billion or nearly one third of what it spent for their care over the four years - if all U.S. hospitals practiced at the high-quality/low-cost standard set by the Salt Lake City region.
The new research is based on Medicare claims data for more than 4,300 hospitals in 306 regions, released today in a new database available at www.dartmouthatlas.org.
“The problem of overuse of acute care hospitals and medical specialists in the management of chronic illness is rapidly getting worse,” said Wennberg.
He points to finding that the resources per capita allocated to managing chronic illness during the last two years of life are increasing steadily each year. For example, the nation’s health care providers were using 13.6 percent more ICU beds in 2003 than they did in 2000. Physician labor used to manage chronic illness also increased substantially: 13.4 percent for medical specialists and 7.7 percent for primary physicians. The acceleration was greatest in regions that were already using the most care, so the gap between high and low rate regions grew greater over the four years.
Both doctors and patients generally believe that more services - that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc. - produces better outcomes.
Based on this assumption, the supply of resources - not the incidence of illness - drives utilization of the services. In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.
“This report should end the ‘more is better’ myth in health care,” said Donald M. Berwick, M.D., M.P.P., president and CEO of the Institute for Healthcare Improvement (IHI) and a leading national authority on health care quality and improvement issues. “The nation can do a lot to improve the quality and lower the cost of health care once providers, policymakers, payers and the public share an understanding that ‘more care’ is not by any means always ‘better care,’ and that new technologies and hospital stays can sometime harm more than they help.”
Press release:
http://www.dartmouthatlas.org/press/2006_atlas_press_release.shtm
>From the Executive Summary
The reallocation of resources from the acute care sector to create a population-based, community-wide integrated system for managing severe chronic illness is today only a thought experiment. It should become a national goal. Realizing the savings that better organized care can bring requires building community-wide systems of coordinated care. In most communities, such systems do not now exist. The benchmarks from efficient practice indicate that Medicare already invests more than enough money to build and maintain such a system. The problem is that the resources are now largely locked in by Medicare’s reimbursement policy. To meet their payrolls and amortize their debts, acute care hospitals are dependent on utilization; reduced utilization results in loss of income. In many regions the reduction in utilization required to meet efficiency benchmarks would have serious - indeed, devastating - consequences for acute care hospitals. Finding a solution will require payers, particularly Medicare, to develop new methods of financing care that provides a fiscal “safe landing” for hospitals and retained savings for use in building community-based systems for managing severe chronic illness. It will also require accountability for system integration. With proper reform of financial models, large group practice and integrated care systems should be able to provide this accountability for the populations they serve in regions where such practices exist.
Through economic incentives, existing large group practices might be persuaded to accept responsibility for organizing such care in regions where it does not now exist. Traditionally, hospitals have served as the focus for coordinating community resources. They are the only locus of organized care available throughout the United States; perhaps acute care hospitals could take on the mission of integrating providers into community-based systems for managing chronic illness.
Executive Summary:
http://www.dartmouthatlas.org/atlases/2006_Atlas_Exec_Summary.pdf
The full report (121 pages);
http://www.dartmouthatlas.org/atlases/2006_Chronic_Care_Atlas.pdf
Comment:
By Don McCanne, M.D.
Can you imagine the private insurance industry leading the process to reform the management of chronic illness? Our fragmented model of competing payers is not capable of promoting system integration. Not even Medicare has the clout to reorganize the health care delivery system.
If we had a single, publicly-administered national health insurance program, a Medicare-for-All, then we would be in a position to allocate our health care spending in a manner that would integrate our entire health care delivery system. If that would result in a savings for Medicare alone of $40 billion over three years, just think of how much that would save for our entire health care system. And that doesn’t even include the other savings possible though a single payer system such as reduction of administrative waste and efficiencies through negotiated purchasing.
This report makes it clear that action is mandated. It is difficult to see where we could begin without the crucial first step of establishing a program of national health insurance.