PNHP

Lack Of Insurance Compounds Chronic Disease Burden

Lack Of Insurance Compounds Chronic Disease Burden

By Joseph Shapiro
NPR
October 20, 2009

It’s dangerous enough to deal with a chronic illness like diabetes or cholesterol. But Americans who don’t have health insurance often have these conditions and don’t even know it.

Chronic health problems can lurk undetected for the uninsured.

The result is that the uninsured often don’t get the medical care they need to maintain their health, says a study just published online by the journal Health Affairs.

Researchers found that about half of all uninsured people who have diabetes (46 percent) or who have high cholesterol (52 percent) had no idea they had those diseases. By contrast, among the insured, only about a quarter were unaware when they had those chronic diseases (23 percent for diabetes; 30 percent for high cholesterol).

Dr. Andrew Wilper, who practices at a Boise, Idaho, clinic affiliated with the University of Washington and a co-author of the study, said there’s sometimes a misperception that even people without insurance get the care they need to manage chronic illness. “I’ve read in the media multiple times that the uninsured do, in fact, have access to health care,” says Wilper, “and I think that notion runs totally counter to my clinical experience and this data reflects the same.”

Wilper and his co-authors, looked at a federal data from the physical exams of sixteen thousand Americans, under the age of 65.

Among the study’s co-authors are two prominent advocates for a single-payer health care system: Dr. Steffie Woolhandler and Dr. David Himmelstein, both of whom teach at Harvard Medical School. Woolhandler said the “shocking” percentage of people with insurance who still go without discovery or treatment of chronic illness probably reflected high co-payments and deductibles that “often make care and medications unaffordable”. In a press release with the report, she argued, “only single-payer national health insurance would make care affordable for the tens of millions of Americans with chronic illness.”

An earlier study by the same researchers, published last month in the on line edition of the American Journal of Public Health, said that about 45,000 deaths a year can be attributed to a lack of health insurance–more than the deaths caused by kidney disease.

The government estimates 46 million people in America are without health insurance.

http://www.npr.org/blogs/health/2009/10/lack_of_insurance_compounds_ch.html

Doctor panel advocates Medicare-for-all legislation

By Patricia C. McCarter
Huntsville Times
October 21, 2009

HUNTSVILLE, AL — Asked how many people knew someone who had died because they couldn’t afford medical care, five of the 70 people at the Health Care is a Human Right physicians panel discussion stood up.

Asked how many knew someone who “suffered unnecessarily” for the same reason, almost everyone at the Tuesday night meeting at St. Bartley Primitive Baptist Church rose.

Huntsville pediatrician Pippa Abston, a leading voice for the all-volunteer North Alabama Healthcare for All, called those numbers “abominable.”

“These are real people,” said Abston, adding that 19 Alabamians die every week because they can’t afford care.

North Alabama Healthcare for All has sponsored other forums since national medical insurance became such a hot topic this summer, but this one was designed to focus on how people of color are impacted.

Dr. Celia Lloyd-Turney is medical director of the nonprofit Choice Medicine clinic in Toney and local chapter president of the National Medical Association, which is composed of African-American doctors. She said that poverty has caused blacks to get lesser medical treatment than other patients, and that her race tends to suffer more from diabetes, high pressure and kidney failure.

But even if all Americans had the same insurance, she said some doctors wouldn’t give blacks the same level of care because of prejudice.

Abston said Medicare-for-all couldn’t erase prejudice, but it would at least enable all people to get a doctor’s appointment. The pediatrician also agreed with a woman who commented that it would be hypocritical and morally wrong to leave out 13 million illegal immigrants.

The third doctor on the panel was Birmingham’s Wally Retan, state coordinator of Health Care for Everyone. He said most people who don’t approve of such an “incredibly simple” single-payer program distrust government, already like what they have, fear enormous tax increases or feel “better the devil you know than the devil you don’t.”

Regardless, he said he believed that reform could happen, and he even began a brief chant of “Yes, we can,” President Barack Obama’s campaign slogan.

The group endorses HR676, proposed by Democratic Congressman John Conyers of Michigan.

http://blog.al.com/breaking/2009/10/doctor_panel_advocates_medicar.html

Kitzhaber on health care costs

Dr. John Kitzhaber's Unorthodox Ideas On Reforming Health Care

By J. Duncan Moore Jr.
Kaiser Health News
October 21, 2009

Q. Why are you running for governor again?

A. Costs for health care are going to continue to escalate and states will be overwhelmed. Whatever comes out of Congress this year is not going to have much impact on overall costs.

Q. How do you feel about the reform effort in Congress?

A. I’m not optimistic. I think Washington, D.C., is really badly broken. The discussion today is not about health care, it’s about both parties trying to position themselves for future majorities.

http://www.kaiserhealthnews.org/Checking-In-With/checking-in-with-kitzhaber.aspx

And…

Evaluating Health Care Plans: An Analysis of the Short- and Long-Term Fiscal Implications of Reform Plans

US Budget Watch
(supported by Pew Charitable Trusts)
October 19, 2009

Unfortunately, each bill making its way through Congress has employed at least one of these gimmicks:

* Timing Gimmicks
* Loopholes
* Omissions
* Bogus Offsets

… many provisions within the bills… would result in increases of overall health care costs.

http://crfb.org/document/evaluating-health-care-plans

Comment:

By Don McCanne, MD

The five reform bills passed by House and Senate committees will not control health care costs, and yet these are to be merged into one bill – that will not control health care costs.

What is the worst that could happen?

The second worst is that the final bill could be defeated and everyone would walk away with yet another failed attempt at reform. (Everyone would understand that very soon we would have to return to start over since the status quo is totally unacceptable.)

The very worst is that this bill could pass and everyone would walk away insisting that we have successfully reformed health care when all we have done is to establish an unnecessary and unethical ten-year long experiment that will cause financial hardship, physical suffering and even death – adverse outcomes that could be prevented with reform based on policy evidence rather than markets.

The goal of completing action on this bill before Christmas, pass or fail, and then walking away is not acceptable. We must set this bill aside and start fresh with a model that would prevent yet another decade of unnecessary grief. That model, of course, is an improved Medicare for all.

Insurance promotes awareness and control of chronic disorders

Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults

by Andrew P. Wilper, Steffie Woolhandler, Karen E. Lasser, Danny McCormick, David H. Bor, and David U. Himmelstein
Health Affairs
October 20, 2009

Abstract: In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured.
Unrecognized or undertreated disease places uninsured people at risk for costly, disabling, or even lethal complications. For instance, many cases of kidney failure, blindness, and amputation are preventable through good diabetes control. Hypertension control is the major strategy used to combat stroke.
For the uninsured, recognition of these three conditions lags behind that of people with health insurance. Insuring the uninsured may improve care and reduce rates of disabling complications and death for Americans with these chronic illnesses.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.6.w1151v1

This study confirms that being insured not only improves the control of chronic diseases, it also improves the diagnosis in individuals who are not even aware of their disorders. Insuring the uninsured can delay or even totally prevent the disastrous complications of these chronic disorders.
Current legislative proposals would leave perhaps tens of millions of individuals without insurance coverage. We cannot afford to complete the reform process until we establish policies that would cover absolutely everyone.
Our representatives in Congress need to halt the process now while they take another look at a single payer national health program – an improved Medicare for all – which actually would cover everyone. The House will have a chance to do so in the next few weeks when Rep. Anthony Weiner introduces his amendment on the House floor that would replace the language of the reform bill with the language of the single payer model.
Those who have not done so already may be interested in watching the seven minute video of Rep. Weiner’s statement when he previously introduced the single payer amendment in committee:
http://weiner.house.gov/tv.aspx?p=112

Chronic illnesses more often undiscovered, undertreated in uninsured

By Elizabeth Cooney
Boston Globe
October 20, 2009

Uninsured people are also more likely to have undiagnosed and undertreated medical conditions, according to a new study comparing chronic illnesses among Americans with and without health coverage. The results offer possible clues to a recently reported higher death rate among people who lack insurance.

Researchers from Cambridge Health Alliance and Boston Medical Center tracked diabetes, high blood pressure, and high cholesterol in a national survey of more than 15,000 working-age adults. Based on questionnaires, medical exams, and lab test results, they found that about half of uninsured people who had diabetes or high cholesterol were unaware of it, compared with just under one-quarter of insured people who did not know they had these conditions. High blood pressure, however, was undiagnosed in about a quarter of both uninsured and insured people.

Once diagnosed, hypertension was poorly controlled in 58 percent of uninsured people and 51 percent of those with insurance. The treatment gap was larger for high cholesterol: 77 percent of uninsured versus 60 percent of insured people had inadequately treated levels.

For diabetes control, the difference in treatment was not as clear. Insurance status did not matter in achieving good diabetes control, as defined by the national survey conducted by the US Centers for Disease Control and Prevention. But using less stringent measures that the authors say are more commonly used by physicians, 31 percent of uninsured diabetics were in poor control of their blood sugar levels, compared with 25 percent of insured diabetics.

“The diagnosis and control of chronic illness is substandard even in people with insurance,” Dr. Steffie Woolhandler, co-author of the article appearing online today in Health Affairs, said in an interview. “But it’s much, much worse for the uninsured.”

Woolhandler said the study results fit with research published last month linking 45,000 deaths each year to the lack of insurance. The same group wrote both articles.

“We know that you can prevent deaths through good treatments for high blood pressure, for diabetes, and for high cholesterol,” she said. “These common conditions are easily treated, but if you don’t treat them, they can turn lethal.”

Chronic conditions are diagnosed and treated through regular doctors’ visits and medication regimens, both of which can be out of reach for the uninsured, Woolhandler said.

The study’s conclusions are not surprising, according to Lindsey Tucker, Health Reform Policy Manager for the advocacy group Health Care For All.

“This paper demonstrates yet again the importance of having and retaining health insurance,” she said in an e-mail interview. “As we know from our policy work as well as from our HelpLine callers, uninsurance is costly not only for the individual but also for the state and the health care system.”

http://www.boston.com/news/health/blog/2009/10/post_33.html

Insurance promotes awareness and control of chronic disorders

Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults

by Andrew P. Wilper, Steffie Woolhandler, Karen E. Lasser, Danny McCormick, David H. Bor, and David U. Himmelstein
Health Affairs
October 20, 2009

Abstract: In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured.

Unrecognized or undertreated disease places uninsured people at risk for costly, disabling, or even lethal complications. For instance, many cases of kidney failure, blindness, and amputation are preventable through good diabetes control. Hypertension control is the major strategy used to combat stroke.

For the uninsured, recognition of these three conditions lags behind that of people with health insurance. Insuring the uninsured may improve care and reduce rates of disabling complications and death for Americans with these chronic illnesses.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.6.w1151v1

Comment:

By Don McCanne, MD

This study confirms that being insured not only improves the control of chronic diseases, it also improves the diagnosis in individuals who are not even aware of their disorders. Insuring the uninsured can delay or even totally prevent the disastrous complications of these chronic disorders.

Current legislative proposals would leave perhaps tens of millions of individuals without insurance coverage. We cannot afford to complete the reform process until we establish policies that would cover absolutely everyone.

Our representatives in Congress need to halt the process now while they take another look at a single payer national health program – an improved Medicare for all – which actually would cover everyone. The House will have a chance to do so in the next few weeks when Rep. Anthony Weiner introduces his amendment on the House floor that would replace the language of the reform bill with the language of the single payer model.

Those who have not done so already may be interested in watching the seven minute video of Rep. Weiner’s statement when he previously introduced the single payer amendment in committee:
http://weiner.house.gov/tv.aspx?p=112

Illness often undiscovered and undertreated among the uninsured

Harvard study indicates gaps in care for diabetes, cholesterol, hypertension

EMBARGOED until
Oct. 20, 2009, 12:01 a.m. EDT

Contacts:
Andrew P. Wilper, M.D.
Steffie Woolhandler, M.D., M.P.H.
David Himmelstein, M.D.
Mark Almberg, (312) 782-6006, mark@pnhp.org

A new study shows uninsured American adults with chronic illnesses like diabetes or high cholesterol often go undiagnosed and undertreated, leading to an increased risk of costly, disabling and even lethal complications of their disease.

The study, published online today [Tuesday] in Health Affairs, analyzed data from a recent national survey conducted by the Centers for Disease Control and Prevention (CDC). The researchers, based at Harvard Medical School and the affiliated Cambridge Health Alliance, analyzed data on 15,976 U.S. non-elderly adults from the National Health and Nutrition Examination Survey (NHANES), a CDC program, between 1999 and 2006.

Respondents answered detailed questions about their health and economic circumstances. Then doctors examined them and ordered laboratory tests.

The study found that about half of all uninsured people with diabetes (46 percent) or high cholesterol (52 percent) did not know they had these diseases. In contrast, about one-quarter of those with insurance were unaware of their illnesses (23 percent for diabetes, 29.9 percent for high cholesterol).

Undertreatment of disease followed similar patterns, with the uninsured being more likely to be undertreated than their insured counterparts: 58.3 percent vs. 51.4 percent had their high blood pressure poorly controlled, and 77.5 percent vs. 60.4 percent had their high cholesterol inadequately treated.

Surprisingly, being insured was not associated with a widely used measure of diabetes control (a hemoglobin A1c level below 7), a finding the authors attribute to the stringent definition of good diabetes control used in the NHANES survey. Even with excellent medical care, many diabetics fail to achieve such low hemoglobin A1c levels. Using less stringent hemoglobin A1c thresholds of 8 and 9, uninsured adults had significantly worse blood sugar control than their insured counterparts, the researchers found.

Lead author Dr. Andrew Wilper, who worked at Harvard when the study was done and who now teaches at the University of Washington Medical School, said: “Our study should lay to rest the myth that the uninsured can get the care they need. Millions have serious chronic conditions and don’t even know it. And they’re not getting care that would prevent strokes, heart attacks, amputations and kidney failure.”

Referring to a study released in the American Journal of Public Health last month, which has been widely quoted by Sen. Max Baucus and others, he added: “Our previous work demonstrated 45,000 deaths annually are linked to lack of health insurance. Our new findings suggest a mechanism for this increased risk of death among the uninsured. They’re not getting life-saving care.”

Dr. Steffie Woolhandler, professor of medicine at Harvard and study co-author, said: “The uninsured suffer the most, but even Americans with insurance have shocking rates of undertreatment, in part because high co-payments and deductibles often make care and medications unaffordable. We need to upgrade coverage for the insured, as well as covering the uninsured. Only single-payer national health insurance would make care affordable for the tens of millions of Americans with chronic illnesses.”

Dr. David Himmelstein, associate professor of medicine at Harvard and study co-author, said: “The Senate Finance Committee’s bill would leave 25 million Americans uninsured and unable to get the ongoing, routine care that could save their lives and prevent disability. No other wealthy nation tolerates this, yet Congress is turning its back on tens of millions of Americans.”

****

“Hypertension, diabetes and elevated cholesterol among insured and uninsured adults,” Andrew P. Wilper, M.D., M.P.H.; Steffie Woolhandler, M.D., M.P.H.; Karen Lasser, M.D., M.P.H.; Danny McCormick, M.D., M.P.H.; David H. Bor, M.D.; David U. Himmelstein, M.D. Health Affairs, Oct. 20, 2009.

Physicians for a National Health Program (www.pnhp.org) is a research and educational organization of 17,000 doctors who support single-payer national health insurance. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

A Government Takeover of Health Care, with Higher Costs, and even Worse Care??

By Clyde Winter
Hearts and Minds Blog
http://clydewinter.wordpress.com/
October 9, 2009

All of the grassroots efforts for the substantive, effective health care reform that is so needed by American families, have been attacked — for months, for years, and for decades — by insurance corporations, their corporate allies, and now the crass strategists within both major political parties. A health care crisis has thus materialized and been getting worse fast.

The words “public option”, have received overwhelming public support in national polls this year when contrasted with the status quo in health care. However, the public option plan(s) proved vulnerable to certain attacks from the professional spin-meisters who are working to derail any substantive health care reform. Here are three of the most effective attacks recently made on “public option” health care reform efforts. The response that is necessary concludes this essay.

1. The public option would mean a government takeover of health care. They ask, “Do you want the government getting between you, your doctor, and your health care?”

2. The public option, and the bills currently being talked about by politicians and talking heads, will cost lots more than what is currently being spent on health care in America, and that would make the already horrendous deficit even worse. They ask, “Who’s going to pay for this?”.

3. The public option and the bills currently talked about in the newspapers and TV and radio, will cause Medicare to be robbed, and health care for elders to be curtailed. They ask, “Do you want these reformers to establish death panels and pull the plug on Granny?”

What should be our answers to these ridiculous, phony attacks on the health care reform needed in America? These attacks on the public option plan have clearly shown a major mistake was made in allowing the Medicare for All solution to the health care crisis to be taken “off the table” before there was even a public discussion of it. Eliminating the Medicare for All solution from the public discussion for meaningful health care reform has (so far) kept us from neutralizing those attacks. It is plain stupid (or a betrayal) to leave only one confusing, undefined, flip-flopping proposal on the table to be attacked from all directions. The people can’t fight the odds against true reform with one hand tied behind our back and the other hand not knowing how to punch.

It is easy for anyone to explain or quickly understand the Medicare for All solution to the health care crisis. It proposes to strengthen and enhance Medicare, and expand it to provide comprehensive health care to ALL Americans, throughout life, with no co-pays and no deductibles. The Congressional Budget Office has reported that the amount of money that would be saved by changing the administration of the existing health care system from for-profit insurance corporations to Medicare would be more than enough to provide universal coverage for everyone. Medicare for All is supported by a wide majority of nurses and physicians that provide primary health care, and by a majority of American families (despite the powerful efforts to put it “off the table” and keep it out of view). Medicare for All (HR 676) clearly defines the health care crisis, identifies the primary reason for it, and presents a simple, understandable, proven workable solution, in a 15-page bill that anyone can read. So here are (or should be) our answers to the attacks levied against the public option and health care reform:

First, the government did not “take over” and harm the health care of those over 65, or the disabled, when Medicare was established in 1965, or the health care of those who now serve or have served in the armed forces, or the excellent health care provided by these military facilities to our Presidents, members of Congress, and their families. Caregivers providing health care today are faced with intervention and interference from insurance corporations, but not from Medicare. Where would American families be today, and where would elders and the disabled be, if the insurance corporations had continued to administer and be the gatekeepers of their health care, instead of Medicare? How many elders would have lived and died uninsured, under-insured, and without needed care, and how many more families would have gone bankrupt trying to help their elder members get the health care they need? Everyone needs to be reminded that health insurance corporations and their allies interfere with families’ choice of providers, and with needed treatment plans and prescriptions. The excellent active duty military family medical care system (which IS a completely government owned and operated system of “socialized medicine”) and Medicare (which is NOT) do not let administrators get between the doctors and their patients, like the insurance corporations do, who insist it is their right. We should loudly and clearly say that, “American families have a right to get health care we need without insurance corporations getting anywhere between health care providers and the people”.

Second, with regards to projected financial costs, we should simply and clearly say, “Hey, if you don’t like the up front cost of the ‘public option’ then look at Medicare for All! HR 676 would save four hundred billion annually in unnecessary, wasted expenditures, easily providing universal comprehensive health care with no deductibles or co-payments, and no increased outlay. Enhanced Medicare for All is clearly the most fiscally conservative solution to the health care crisis, from both the standpoint of individual American families, and from the standpoint of the American economy (to say nothing of providing the best health care outcomes).” If you insist on keeping the insurance corporations in the role of gatekeeper and administrator, then America will be forced to pay a costly premium. Let American families (not behind-the-scenes corrupt and greedy power brokers) make the choice between Medicare for All and the new, compromise public option idea, which retains insurance corporations as gatekeepers and administrators, and does nothing to end the costly, complicated billing procedures and eligibility determinations, the gross profits and outrageous pay to executives.

Third, orchestrated astroturf opposition surged this summer against the changing, confusing varieties of the thousand-plus page HR 3200, or the unspecified “President’s plan”, or the “Kennedy memorial” plan, or the ironically solo/bipartisan “Baucus/lobbyists plan”. This opposition to health care reform planted and exploited fear that Medicare would be fleeced, health care for elders pinched, and “the plug would be pulled on Granny” to pay for the costs of whatever plan might emerge from the confusion. This fear is obviously and easily countered by HR 676, Medicare for All, which simply proposes to enhance and strengthen Medicare, and extend it to all Americans of all ages. That would both make Medicare stronger, and protect health care for seniors against future possible attempts to impose budget cuts on it. (And budget cuts will continue to be promoted if Medicare continues to be only for the elderly and the disabled.) True health care reformers need to say, “So you think the ‘public option’ proposal threatens health care for seniors? Then check out Medicare for All. If you really want to protect Medicare and health care for seniors and the disabled, then adopt Enhanced Medicare for All. Nobody is going to get away with cutting Medicare for elders if Medicare covers every member of the family.”

A so-called “reform” that leaves the insurance corporations in place as the administrators in charge of the health care system in America, while even further increasing their massive power and wealth by mandating everyone in America to purchase their flawed products (with their profits further enhanced by taxpayer funded subsidies) is regarded as nothing but a sham and a fraud by everyone except the insurance corporations and their lobbyists and allies, and a very small percentage of the public that is best described as woefully uninformed.

Deciding that Medicare for All (HR 676) should be marginalized and dismissed because it is deemed to currently “not have the votes in Congress to pass” is a self-fulfilling prophecy, an abject surrender to corruption, and a losers way to play a winning hand. It should now be clear to all that discarding the trump card of Medicare for All is such an obvious and continuing mistake, that the old maxim, “follow the money”, provides the only possible explanation. And a sad and sorry one it is, implying pervasive corruption in both major political parties and unwillingness by both parties to reject government that is by and for the corporations and the lobbyists, instead of the people. Over a million dollars is being spent every single day by corporate vested interests just in lobbying the 535 members of Congress to prevent the people from getting the health care reform all America so badly needs. And this is on top of the billions in campaign and PAC “contributions” that have greased elected officials, candidates, and strategists of both major parties, and the billions more to come. That is just part of the huge hidden cost of compromised health care and of corrupted government that American families will have to keep paying — until we ourselves put an end to it.

The people should have a choice between a strong public option and enhanced Medicare for All, and should be provide accurate, understandable information about each. Such information about the Medicare for All, solution to the health care crisis has long been available, but has been taken “off-the-table” by corporate lobbyists, by the mass media and by corrupted strategists running both major parties. American families don’t need a choice in health insurance plans and policies. (Most people don’t really have one now, anyway, and will not have one with any public option proposal that emerges.) We want choice of health care providers. We need lower costs, more financial and health security, better health care outcomes, and a stronger economy for the people. And we will get it, with Enhanced Medicare for All (HR 676).

If we truly want to get the health care America needs, we will also need to get a government that is of, by, and for the people, instead of government that is by and for the corporations and the lobbyists. Contact your choice of the following national organizations now to see what you can do to help the grassroots effort to get the health care America needs.

http://clydewinter.wordpress.com/2009/10/09/a-government-takeover-of-health-care/

Dartmouth variations – looking back and looking forward

Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure

By Michael K. Ong, Carol M. Mangione, Patrick S. Romano, Qiong Zhou, Andrew D. Auerbach, Alein Chun, Bruce Davidson, Theodore G. Ganiats, Sheldon Greenfield, Michael A. Gropper, Shaista Malik, J. Thomas Rosenthal and José J. Escarce
Circulation – Journal of the American Heart Association
October 13, 2009
Background: Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined.
Methods and Results: (Warning: This section is technical and you may want to skip it for now.) A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission (“Looking Forward”). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death (“Looking Back”). “Looking Forward” risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were 0.68 between mortality and hospital days, and 0.93 between mortality and indexed total direct costs. “Looking Back” risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences.
Conclusions: California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.
WHAT IS KNOWN
* Substantial variation has been documented among hospitals in the resources used to care for elderly Medicare beneficiaries with chronic illnesses during the last 6 months of life.
* By only including individuals who have died in the analyses, researchers cannot identify differences on health outcomes such as survival.
WHAT THE STUDY ADDS
* This study found variation among California teaching hospitals in survival for patients hospitalized with heart failure. This variation would have been overlooked by a study that only examined heart failure patients who died.
* When analyzing all patients hospitalized for heart failure, California teaching hospitals that used more resources had lower mortality rates.
* When analyzing all patients hospitalized for heart failure, the variation in resource use among California teaching hospitals was 27% to 44% less than the variation observed when analyzing only heart failure patients who died.
http://circoutcomes.ahajournals.org/cgi/rapidpdf/CIRCOUTCOMES.108.825612v1.pdf

As the nation attempts to identify ways of slowing the excessive growth in our health care costs, it is only natural that we would look at the great variability in health care spending that does not seem to correlate with health care outcomes. John Wennberg and his colleagues, in producing the Dartmouth Atlas, have confirmed that these variations are very real, though more recent refinements have demonstrated that the differences are not quite as great when corrected for other factors.
A prior study of California hospitals showed that these differences were not limited to those areas for which there seems to be an easier explanation (private hospitals with a liberal supply of high-tech services and professionals treating wealthier patients versus under-budgeted safety-net institutions treating low-income patients), but these Dartmouth differences were also noted between the various University of California teaching hospitals, which have similar funding, staffing and equipment.
This new study looked closer at the differences between the University of California teaching hospitals (including one private teaching hospital affiliated with UCLA). The authors showed that looking back for six months at patients who had died of heart failure did confirm the differences, although not as great since more variables were considered. Higher spending did not improve outcomes for the obvious reason that patients were selected for study on the basis of a common outcome – death.
The important contribution of this study is that they selected the same disorder as used in the death study – congestive heart failure – and looked forward for six months for the outcome of survival or death. This study showed that the teaching hospitals using more resources (spending more money) had a lower incidence of death.
Okay. Now, what care are we going to refuse to fund? Just looking at congestive heart failure alone, it is going to be very difficult to sort out the details to determine which interventions are of value and which are not. Now think of the task of sorting out these differences for all other serious disorders.
So how do we select out those services that should be eliminated from coverage? Legislators and bureaucrats certainly understand that they are not up to the task, so what do they recommend? They are suggesting that we lower spending by paying only for efficient care (i.e., by paying less money), by bundling payments and using accountable care organizations. Third party payers would distribute the funds while health care professionals would micromanage the use of those funds.
Think of the logistical nightmare of contracting with all the services and facilities that would be required in an accountable care organization. Even just informally gathering these services together to accept a bundled payment would entail similar logistical barriers. But then think of the internal conflicts that would occur when it comes time to decide how to divide up the spoils. The micromanagement within these entities would not be based on projected optimal outcomes, but they would be based on pecuniary interests.
If high-quality teaching institutions within the same university system are having difficulties fine tuning health care, how could we ever expect all facilities throughout the nation to adhere to the highest standards when they aren’t even understood?
Although we can continue to study the differences and educate professionals on better practices, we can’t really look to the Dartmouth variations as a quick source of cost savings to finance our other health care needs.
But there is one quick measure that would provide a great start for achieving a higher-value health care system. Get rid of the private insurers and establish an improved Medicare system that would include all of us. That would save about $4 trillion in the next ten years that could be used on actual health care, without increasing our national budget deficit. With a single financin

Dartmouth variations – looking back and looking forward

Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure

By Michael K. Ong, Carol M. Mangione, Patrick S. Romano, Qiong Zhou, Andrew D. Auerbach, Alein Chun, Bruce Davidson, Theodore G. Ganiats, Sheldon Greenfield, Michael A. Gropper, Shaista Malik, J. Thomas Rosenthal and José J. Escarce
Circulation – Journal of the American Heart Association
October 13, 2009

Background: Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined.

Methods and Results: (Warning: This section is technical and you may want to skip it for now.) A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission (“Looking Forward”). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death (“Looking Back”). “Looking Forward” risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were 0.68 between mortality and hospital days, and 0.93 between mortality and indexed total direct costs. “Looking Back” risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences.

Conclusions: California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.

WHAT IS KNOWN

* Substantial variation has been documented among hospitals in the resources used to care for elderly Medicare beneficiaries with chronic illnesses during the last 6 months of life.

* By only including individuals who have died in the analyses, researchers cannot identify differences on health outcomes such as survival.

WHAT THE STUDY ADDS

* This study found variation among California teaching hospitals in survival for patients hospitalized with heart failure. This variation would have been overlooked by a study that only examined heart failure patients who died.

* When analyzing all patients hospitalized for heart failure, California teaching hospitals that used more resources had lower mortality rates.

* When analyzing all patients hospitalized for heart failure, the variation in resource use among California teaching hospitals was 27% to 44% less than the variation observed when analyzing only heart failure patients who died.

http://circoutcomes.ahajournals.org/cgi/rapidpdf/CIRCOUTCOMES.108.825612v1.pdf

Comment:

By Don McCanne, MD

As the nation attempts to identify ways of slowing the excessive growth in our health care costs, it is only natural that we would look at the great variability in health care spending that does not seem to correlate with health care outcomes. John Wennberg and his colleagues, in producing the Dartmouth Atlas, have confirmed that these variations are very real, though more recent refinements have demonstrated that the differences are not quite as great when corrected for other factors.

A prior study of California hospitals showed that these differences were not limited to those areas for which there seems to be an easier explanation (private hospitals with a liberal supply of high-tech services and professionals treating wealthier patients versus under-budgeted safety-net institutions treating low-income patients), but these Dartmouth differences were also noted between the various University of California teaching hospitals, which have similar funding, staffing and equipment.

This new study looked closer at the differences between the University of California teaching hospitals (including one private teaching hospital affiliated with UCLA). The authors showed that looking back for six months at patients who had died of heart failure did confirm the differences, although not as great since more variables were considered. Higher spending did not improve outcomes for the obvious reason that patients were selected for study on the basis of a common outcome – death.

The important contribution of this study is that they selected the same disorder as used in the death study – congestive heart failure – and looked forward for six months for the outcome of survival or death. This study showed that the teaching hospitals using more resources (spending more money) had a lower incidence of death.

Okay. Now, what care are we going to refuse to fund? Just looking at congestive heart failure alone, it is going to be very difficult to sort out the details to determine which interventions are of value and which are not. Now think of the task of sorting out these differences for all other serious disorders.

So how do we select out those services that should be eliminated from coverage? Legislators and bureaucrats certainly understand that they are not up to the task, so what do they recommend? They are suggesting that we lower spending by paying only for efficient care (i.e., by paying less money), by bundling payments and using accountable care organizations. Third party payers would distribute the funds while health care professionals would micromanage the use of those funds.

Think of the logistical nightmare of contracting with all the services and facilities that would be required in an accountable care organization. Even just informally gathering these services together to accept a bundled payment would entail similar logistical barriers. But then think of the internal conflicts that would occur when it comes time to decide how to divide up the spoils. The micromanagement within these entities would not be based on projected optimal outcomes, but they would be based on pecuniary interests.

If high-quality teaching institutions within the same university system are having difficulties fine tuning health care, how could we ever expect all facilities throughout the nation to adhere to the highest standards when they aren’t even understood?

Although we can continue to study the differences and educate professionals on better practices, we can’t really look to the Dartmouth variations as a quick source of cost savings to finance our other health care needs.

But there is one quick measure that would provide a great start for achieving a higher-value health care system. Get rid of the private insurers and establish an improved Medicare system that would include all of us. That would save about $4 trillion in the next ten years that could be used on actual health care, without increasing our national budget deficit. With a single financing system, we would then be able to make some gradual headway with the Dartmouth variations.