EDITORIAL: More care, less quality

Apr. 15, 2008 (McClatchy-Tribune Regional News delivered by Newstex) --
Medicare beneficiaries in North Dakota enjoy some of the highest quality health care in the U.S. at the lowest price. That's true even though North Dakota is a rural state with chronic shortages of physicians.

In fact, it's probably true because North Dakota is a rural state with chronic shortages of physicians.

In other industries, making a product more available tends to drive down its price. But health care is different. Making it more available tends to pump up its price: "(I)t is the supply of beds and treatments and specialists -- not how sick people are -- that determines how much they get used," a new and comprehensive study has concluded.

"The supply of services creates its own demand, so regions with more resources have more usage and thus higher costs."

The federal government should take note.

The new Dartmouth Atlas of Health Care has the data. The atlas is a publication of the Institute for Health Policy and Clinical Practice at Dartmouth Medical School. It's a nationwide comparison of the costs and outcomes of treatments of chronically ill Medicare patients.

And the conclusions are stark: "Medicare pays many hospitals and their doctors more than the most efficient and effective health-care institutions to treat chronically ill people, yet gets worse results," according to a summary by the report's sponsor, the Robert Wood Johnson Foundation.

"The Atlas documents that Medicare and most other payers encourage the overuse of acute-care hospital services and the proliferation of medical specialists thanks to misplaced financial incentives, especially for treating chronically ill people."

For example, "an elderly person spent an average of 10.6 days in the hospital during the last two years of life in Bend, Ore., but 34.9 days in Manhattan," the foundation notes.

"The variation is even more striking in the last six months of life, when chronically ill patients visited the doctor an average of 14.5 times in Ogden, Utah, compared to 59.2 times in Los Angeles.

"That creates wild variations in how much Medicare spends on these patients. The U.S. average was $46,412. The highest spending was in New Jersey at $59,379 per patient, or a quarter more than average. The lowest was in North Dakota at $32,523 per patient, or a quarter less than average."

And that's true even though Oregon, Utah and North Dakota score very well on indicators of the quality of care.

As the foundation declares, "the Atlas research shows that hospitals, regions and states that use more services per patient do not necessarily have higher quality care. In fact, it is slightly worse."

The report makes several policy suggestions. They include a more rational approach to chronic illness, especially one that depends more on proven "best practices" of low-cost, high-quality leaders such as the Mayo Clinic and less on doctors' subjective judgments; and "shared savings" incentives that reward low-cost systems for staying efficient and high-cost systems for cutting overuse.

Meanwhile, North Dakotans and Minnesotans alike can be proud of their status. The states have long enjoyed reputations as places where public schools, law enforcement and other services "work." Health care should be added to that list because the states have been shown to be national leaders in providing high-quality, low-cost care.


Tom Dennis for the Herald



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