Our ability to constrain American health spending may lie in the
answer to one basic -- and increasingly contentious question --
whether patients with the same condition basically get the same care
whether they are treated by doctors and hospitals in Manhattan or
Minneapolis.
If they do, we've got a serious problem and will have to drastically
ratchet back our anticipated savings from estimated efficiencies. If
they don't -- a position embraced by President Obama and those around
him -- savings exceeding 25% are very possible, albeit difficult to
achieve.
This is quietly becoming the Big Issue in the health reform debate
and pits reformers against respected physicians and hospitals who
require a very different response than the one used on cable
television yellers who fixate on death panels.
Among those pushing reform there's a belief that up to 30% of what
is spent in high-cost areas like New York, Miami and Boston goes for
care that's unneeded and does nothing to improve outcomes. If all
patients could be treated in a way already typical in low-cost areas
like Minneapolis and Santa Fe, reformers say, care would be much more
affordable.
The challenge, they say, lies in transplanting the patterns already
typical in the low-cost areas to the high-cost areas, which no one
thinks will be easy. That's what feeds the focus on evidence-based
medicine.
Unsurprisingly, those providing care in high-cost areas, who tend to
be quite sophisticated from both medical and media perspectives, have
begun to challenge this logic. They provide more care, they argue,
because their patients are sicker to begin with. The reject the idea
that they could do significantly less without jeopardizing their
current outcome record.
If they are right, it is very hard to see how we can constrain
exploding health spending. If they're wrong, the task is difficult,
but at least definable. Fortunately, there's reason to conclude they
are wrong. Unfortunately, given the stakes, there's little chance
they'll quickly retreat.
The case for geographic disparities has been repeatedly and
painstakingly made for more than 30 years by Dr. Jack Wennberg.
Their basic conclusion is that there are cultural "patterns of practice" that
differ significantly one from one market to another and are driven largely by supply.
If you have more physicians and hospital beds in a region, they conclude, you're
likely to have more physician visits, tests and procedures.
Their most controversial conclusion is that this disparity influences
spending, but not outcomes. Patients treated in areas where care is
less extensive and aggressive tend to recover just as quickly, they
just come away from the experience with significantly fewer bills.
There's also evidence that institutions that pay doctors salaries
tend to do less while providing high quality care. The Cleveland
Clinic and the Kaiser operations in California are often cited. But
the leading poster child for efficient care is the Mayo Clinic, which
not only has a reputation for providing high-quality care using
salaried physicians, but also has the good fortune to be located in
the Minneapolis area, where there's a generally a very conservative
pattern of practice.
Over the years, there have been some efforts-- basically unsuccessful
-- to challenge the Wennberg data, but the topic was largely academic,
because it ultimately didn't make much difference. No one was
lowering the boom on high-cost areas. Now that there's a real threat
and it is a creating a powerful backlash challenging the Wennberg
thesis, which argues, among other things that supply drives demand and
that an area with many doctors and hospital beds will host many more
expensive procedures than one with fewer medical personnel.
The difference between a high-cost area like New York or Boston and a
low-cost one like Minneapolis of Santa Fe, they say, has little to do
with wage disparities and a lot to do with the number of tests and
procedures are done. The major difference is not that a CAT scan in
Santa Fe is cheaper (it is) because of lower wages there, but rather
that many more of them are done in New York.
If you could introduce Minneapolis medicine to Miami, reformers note,
Medicare could save millions. That's an attractive idea, although no
one quite knows how to implement it.
Some, including those who practice in high-cost areas, think the Mayo
story is a bit distorted and have begun to fight back.
They question not the quality of Mayo medicine but rather the
composition of its patient population. To put it simply, they argue
that Mayo is caring for people of at least middle-class backgrounds
who have lived reasonably healthy lives and had the protection of
health insurance. Given the low uninsured rate in Minnesota, there's
probably at least some truth to that.
The broader argument is similar, suggesting that there's less care
delivered in Minneapolis than New York, not because the doctors are
more cautious, but more often because the patients are healthier.
You don't have to be a conspiracy theorist to acknowledge that similar articles have appeared in recent weeks in the New York Times and Los Angeles Times.
The expensive big-city hospitals are fighting back now that they
realize that reform efforts today are a major threat.
Basically they say that the data Dartmouth data is not adequately
adjusted for health status and that the reason patients in the Bronx
have longer hospital stays, more surgery and added tests is that
they're sicker than patients in Minnesota, not because the doctors
have different patterns of practice. This is a key point and one,
alas, that most of us civilians are incapable of judging. Suffice to
say that previous efforts to undermine the patterns of culture
argument using this argument have failed.
From a narrow procedural perspective, this is disturbing because it
seems to be yet another successful effort to move the debate out of a
public, English-speaking forum into a private, credentialed one
bounded by jargon. That leaves me uncomfortable, not only because it
bars me from participation, but also because it gives the parties at
interest control and suggests a very long time frame.
But the stakes are greater. If the one recipe we have for greater
efficiency is discredited, that sets the whole quest for efficiency
back by decades while sending a signal that any effort that requires
any participant in medicine to make significant changes will probably
provoke a similar nasty response.
In an effort to fight against the trend toward jargon, let me put
this in language than anyone familiar with Hokey Pokey will readily
understand -- that's what its all about.
Before I get too excited about the argument that the Mayo data are skewed by a favorable case mix, I'd like to see the evidence that this is so. As far as I can tell, it's just an assertion that plays well to the political interests of those who make it. In my opinion the Dartmouth data have actually held up very well, in spite of very close scrutiny over the years.
Just as a random example here, obesity is linked to a variety of health ills, and the upper Midwest doesn't look as healthy as much of the Northeast by that measure of health.
I certainly defer, as I have before, to Chris as a physician living in Santa Fe who worked at Mayo. His point is excellent. Unfortunately, this is a political dispute, not a scientific one. In all the assertions of challengers, I've yet to see a single piece of data. rather there are assertions "our patients are sicker." were I cynical I'd ask whether this referred to admission or discharge