Helath Care Costs and Quality of Care

TOPIC: Healthcare Costs and Quality of Care

“The biggest failure of the American health care system is not that we overuse stuff but that we underuse stuff,”
(David Cutler, Economist,Harvard)

Dear Friends and Colleagues:
Attached two articles from the Miami herald and New York Times discussing the paradox of increasing health car costs and decreasing quality of care.
John Dorscher, the renowned Miami Herald health care reporter, reviews the costs, quality and outcome of medical care in South Florida.
Unfortunately, we have the highest per capita healthcare expenditures, but our performance is the lowest in the country.
In plain simple English: our patients (including your employees and families) or their insurance spent the most, but get the short end of the stick.
Among others the following factors contribute to this problem: fragmented health care system, uncoordinated health care delivery, poor or non-existing information sharing resulting in unnecessary duplication of diagnostic testing and absence of quality measures in ambulatory care setting.
Unfortunately, doctors are still resisting to conduct performance and outcome measure assessments.
These measures are not meant to be punitive, but to provide guidance for physicians to assess and compare their performance.
For that purpose I am using for more than seven years an electronic health records and routinely check if the treatment of my patients with certain chronic disease (Diabetes, Hypertension, Asthma) meets the standards of care and complies with national guidelines.
I learn a lot from those routine reviews and adjust my care accordingly.
If I can do it, why do we have to wait for the government to prescribe how we should practice medicine?
Lets take the initiative and implement modern business management principles in our practices including medical information technology.
Looking forward to your comments.
Happy Chanukah and Merry Christmas.
Yours
Bernd






Posted on Sun, Dec. 17, 2006

HEALTHCARE | FIFTH OF AN OCCASIONAL SERIES
High prices don't translate into better healthcare in South Florida
In the still murky world of healthcare information, high costs of healthcare are not at all linked to high quality care in South Florida.
BY JOHN DORSCHNER
jdorschner@MiamiHerald.com

With studies showing that South Florida has among the highest healthcare costs in the country, consumers might assume local hospitals' performance on quality standards would be among the tops in the country.

Think again.

After a thorough examination of quality data made public by Medicare, Harvard researchers have discovered South Florida's performance is among the worst in the country in two out of three key categories.

Their findings reveal what many experts now see as a growing amount of health information becomes available: The relationships among costs, the quality of treatment and ultimate outcome is murky at best. That means measuring proper treatments may not have much to do with costs at the moment -- or even whether the patient lives longer.

Insurers and the federal government want the consumers to have more health information to make better choices and to pay providers according to their performances. In theory, it's great. In reality, providers fear it it may be something else.

''Though I am supporting transparency in healthcare pricing and the patients (sic) right to receive high-quality care, I am concerned that insurers may just focus on cheaper and not necessarily better,'' wrote North Miami Beach doctor Bernd Wollschlaeger in a letter to colleagues after a recent Miami Herald report on healthcare pricing.

In fact, Wollschlaeger believes one problem may be that there is not enough information. One major example: South Florida doctors usually don't know whether the patient received the proper test at the hospital, meaning they frequently order the same test again.

Unnecessary repetition of services and tests, frequently caused by excessive trips to specialists, is one reason why researchers of the Dartmouth Medical School have found that per capita healthcare costs in Miami are almost twice what they are in Minneapolis, another similar-size city they studied.

Contrast that with the findings of four researchers from Harvard's School of Public Health who studied the 40 largest hospital markets in the United States for the basic Medicare quality measures, such as giving aspirin to a patient after a heart attack.

BOTTOM FIVE

In two of the three main categories -- treatment for heart attack and for pneumonia -- the Miami region ranked in the bottom five, the researchers wrote in their article, published in the New England Journal of Medicine. For the third category, congestive heart failure, it didn't do much better, finishing 29th out of 40.

''These are very simple but really important things to perform,'' says Ashish K. Jha, the lead Harvard researcher. ``Aspirins, beta-blockers -- things that can cost pennies but can be crucial.''

Meanwhile, Florida's healthcare dollars are being spent much more frequently, according to a Dartmouth study released in May. During the last six months of life, the average Medicare recipient spends twice as many days in intensive care and has twice as many doctor visits as his counterpart in Utah.

Within Florida, a patient in Miami spends twice as much time in intensive care and sees twice as many specialists in those last six months than does a patient in Fort Myers.

Alan Sager, a Boston University health professor, thinks these big-picture spending contrasts are what the industry should be looking at, not insurers revealing provider prices.

After The Miami Herald ran a report about insurers making public health cost and pricing information as a prelude to steering consumers toward more efficient providers, Sager sent an e-mail to The Miami Herald: ``Shopping by price won't save serious money because it addresses the wrong question. The big question is not, where's the cheapest place to get the operation, MRI or primary care visit? The big question is, do I need the operation, MRI or visit?''

UNNECESSARY EXPENSES

Sager, like many other experts, believes about half of all healthcare expenses are unnecessary, and if needless work could be curtailed, then America could provide healthcare for everyone.

The nonprofit National Committee for Quality Assurance, which has been measuring health plan performance on various measures for a decade, is now starting to look into these broader ''efficiency'' questions.

NCQA is starting a pilot that will go beyond measuring health plans' quality -- making sure diabetics get blood-sugar tests -- to look at cost, and not just for specific measures.

''We're going to focus on the total cost of healthcare,'' says NCQA Vice President Joachim Roski. ``It could mean you spend money in some areas, but not in others. You might spend more on preventive visits or more on pharmacy but spend less on hospitalizations.''

Adjusting for risk factors such as age and health condition, NCQA plans to release its first efficiency data in September 2007. ''The ultimate question is, do organizations in Miami get the same level of quality with the same level of cost?'' says Roski. ``And if not, why not?''

Brian Klepper, head of the Center for Practical Health Reform, agrees that many healthcare dollars are spent on unnecessary care. He thinks a primary cause may be the present fee-for-service model, in which the more doctors do, the more they get paid. He points out that some years ago, when the state lowered provider payments for workers' compensation treatment, the doctors responded by finding more treatments to do on each patient.

Klepper thinks that payment model has to be changed -- so that doctors get sums for a total treatment of an illness, not for each incremental step -- but he also believes that there must be greater transparency in the system.

Klepper and Wollschlaeger, the doctor who is a delegate to the American Medical Association, believe one good way to provide transparency and cut unnecessary costs is to form regional health information systems.

That way, doctors can see online what other providers have already done for a patient, particularly important in South Florida, which has 40 percent more specialists than does Minneapolis -- a fact that Dartmouth researchers believe causes many duplicative services here.

With providers sharing patient information online, that means someone like Wollschlaeger can see that a patient just released from the hospital ''has already had the pneumonia vaccination shot, so I don't have to order another one for $85,'' says Wollschlaeger.

Discussions about forming a network in South Florida, however, are just getting under way. In the meantime, many are still struggling to comprehend the meaning of the data now available.

A study published Wednesday in the Journal of the American Medical Association found that performance measures reported by Medicare for 3,657 hospitals ''are not tightly linked to patient outcomes,'' meaning that hospitals that are doing a good job of giving, say, the beta-blocker at the right moment are not necessarily showing a good job in lowering mortality rates.

''These findings should not undermine current efforts to improve healthcare quality through measurement and reporting,'' wrote the researchers, headed by Rachel M. Werner. ``However, attention should be focused on finding measures of healthcare quality that are more tightly linked to patient outcomes. Only then will performance measurement live up to expectations for improving healthcare quality.''


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December 17, 2006
Economic View
The More You Pay, the Better the Care? Think Twice
By EDUARDO PORTER

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 Jonathan S. Skinner and Douglas 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 David 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. Paul 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.