The Dartmouth Atlas of Health Care 2008

180 Pages·2008·4.44 MB·English

Tracking the Care of Patients

with Severe Chronic Illness
The Dartmouth Atlas of Health Care 2008
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
THE DARTMOUTH INSTITUTE
FOR HEALTH POLICY & CLINICAL PRACTICE
Where Knowledge Informs Change
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
Library of Congress Cataloging-in-Publication Data
The Dartmouth Institute for Health Policy and Clinical Practice
Tracking the Care of Patients with Severe Chronic Illness/The Dartmouth
Institute for Health Policy and Clinical Practice
ISBN 978-0-9815862-0-5
Medical care – United States – Marketing – Maps. 2. Health facilities – United
States – Statistics. I. Title.
Copyright 2008 The Trustees of Dartmouth College
All rights reserved. The reproduction or use of this report in any form or in any
information storage or retrieval system is forbidden without the express written
permission of the publisher.
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
Tracking the Care of Patients with Severe Chronic Illness:
The Dartmouth Atlas of Health Care 2008
Lead Author: John E. Wennberg
Co-Authors: Elliott S. Fisher, David C. Goodman, and Jonathan S. Skinner
Editor: Kristen K. Bronner
Lead Analyst: Sandra M. Sharp
The Dartmouth Institute for Health Policy and Clinical Practice
Center for Health Policy Research
Dartmouth Medical School
Lebanon, New Hampshire 03766
[phone]
http://www.dartmouthatlas.org
The authors wish to thank Shannon Brownlee for editorial assistance.
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
The Dartmouth Atlas Project
Founder: John E. Wennberg, M.D., M.P.H.
Principal Investigator: Elliott S. Fisher, M.D., M.P.H.
Co-Principal Investigator: David C. Goodman, M.D., M.S.
The Dartmouth Atlas of Health Care Working Group
Kristen K. Bronner, M.A.
Thomas A. Bubolz, Ph.D.
Chiang-Hua Chang, M.S.
Vincent J. Fusca III, M.M.S.
Daniel J. Gottlieb, M.S.
Jia Lan, M.S.
Zhao Peng, M.S.
Stephanie R. Raymond, B.A.
Sandra M. Sharp, S.M
Jonathan S. Skinner, Ph.D.
Dean T. Stanley
Jason Sutherland, Ph.D.
Dongmei Wang, M.S.
Phyllis Wright-Slaughter, M.H.A.
Atlas design by
Jonathan Sa’adah and Elizabeth Adams
Intermedia Communications
The research on which the Dartmouth Atlas Project is based was made possible by grants from
The Robert Wood Johnson Foundation
in association with a funding consortium including
The Wellpoint Foundation
The Aetna Foundation
The United Health Foundation
The California Healthcare Foundation
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
Table of Contents
Introduction: Health Care Spending,
the Care of the Chronically Ill, and the Problem of Supply-Sensitive Care .................1
Why do some regions spend more and do more? .....................................................2
When is more care worse? ........................................................................................3
Why we are interested in measuring care at the end of life .......................................4
The contents of this Atlas...........................................................................................5
Chapter 1: Chronic Illness and the Problem of Supply-Sensitive Care .......................9
Is more care better? .................................................................................................11
How can more care be worse? ................................................................................13
Understanding supply-sensitive care .......................................................................13
Implications for patient preferences .........................................................................16
Implications for evaluating efficiency in managing chronic illness ...........................17
Chapter 2: Variation Among States and Regions
in Medicare Spending for Severe Chronic Illness .......................................................21
Variation in Medicare spending among states and regions .....................................22
The relationship between spending, price, and volume ...........................................26
The relationship between sectors of care ................................................................28
Medicare inpatient spending ....................................................................................30
Medicare spending according to sector ...................................................................33
Conclusions .............................................................................................................37
Chapter 3: How America’s Best Hospitals Manage Chronic Illness ..........................39
Variation among America’s best hospitals ...............................................................42
Volume or price: Which matters most? ....................................................................43
How are resources used? ........................................................................................46
How intensely are patients treated? .........................................................................52
Evaluating the relative efficiency of academic medical centers ...............................54
Benchmarking excess spending due to overuse of hospitals and physician visits ..55
Evaluating performance ...........................................................................................56
Assumptions and facts concerning coordination between sectors of care ..............60
Assumptions and facts concerning “systemness” ....................................................61
Care intensity and patient choice .............................................................................62
Conclusions .............................................................................................................64
vi The DarTmouTh aTlas of healTh Care 2008
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
Tracking the Care of Patients with Severe Chronic Illness
Chapter 4: Evaluating the Management of Chronic Illness in Los Angeles ..............67
How Health Care Varies Among Los Angeles Hospitals ..........................................69
The relationship between volume and price among Los Angeles providers ............74
Measuring the Performance of Los Angeles Hospitals ............................................77
Evaluating the performance of Catholic Healthcare West hospitals in Los Angeles 77
Spotlighting variation within Los Angeles neighborhoods ........................................82
The Los Angeles predicament .................................................................................90
Conclusions .............................................................................................................92
Chapter 5: Dealing with Unwarranted Variation ...........................................................93
A strategy for improving the scientific basis of clinical care .....................................94
A strategy for promoting the growth of organized care and reducing overuse .........96
How hospitals might respond ...................................................................................98
How Catholic Healthcare West might respond .......................................................100
Hospital Corporation of America in Florida ............................................................104
How physicians might respond ..............................................................................104
Concerning feasibility .............................................................................................105
Afterword: Accessing Information on the Dartmouth Atlas Website .......................109
Examples of routine reports ...................................................................................112
Appendix on Methods ..................................................................................................119
Databases used in the analysis .............................................................................119
Study populations ..................................................................................................119
Measures of resource inputs..................................................................................122
Measures of utilization ...........................................................................................122
Quality of care indicators .......................................................................................122
Statistical methods .................................................................................................123
Caveats and limitations ..........................................................................................123
Appendix Tables ...........................................................................................................127
vii
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
Tracking the Care of Patients with Severe Chronic Illness
Introduction
Health Care Spending, the Care of the Chronically Ill,
and the Problem of Supply-Sensitive Care
In 2001 the Institute of Medicine (IOM) issued Crossing the Quality Chasm, a report that sent a
wake-up call to patients, providers, and policy makers about the poor quality of American health
care. The IOM argued that one of the central drivers of poor quality has been the unsystematic and
fragmentary nature of our health care delivery system.
Nowhere are the system’s failings more apparent than in the care of the chronically ill. More than
90 million Americans live with at least one chronic illness, and seven out of ten Americans die from
chronic disease. Among the Medicare population, the toll is even greater: about nine out of ten
deaths are associated with just nine chronic illnesses, including congestive heart failure, chronic
lung disease, cancer, coronary artery disease, renal failure, peripheral vascular disease, diabetes,
chronic liver disease, and dementia.
Treating chronic disease is both enormously costly and not particularly effective. Most patients
with chronic disease are treated in episodic fashion by multiple physicians, who rarely coordinate
the care they deliver. As chronic disease progresses, the amount of care delivered and the costs
associated with this care increase dramatically. Patients with chronic illness in their last two years
of life account for about 32% of total Medicare spending, with much of it going toward physician and
hospital fees (Medicare Part A and Part B) associated with repeated hospitalizations.
The IOM’s report and recent figures on escalating costs due to chronic disease have led to increased
attention to the poor quality of health care in America, and a general consensus that improvements
are desperately needed. Yet efforts to improve the quality of care and simultaneously bring down
costs have been hampered to date by several unfounded assumptions about the structure of the
health care industry and how different payment schemes might affect that structure.
This edition of the Dartmouth Atlas will focus on disentangling the phenomenon known as “unwar-
ranted variation,” or variation in different regions of the country that is not explained on the basis
of illness, patient characteristics or preferences, or the dictates of evidence-based medicine (see
box). Like the last edition, it focuses on supply-sensitive care delivered to chronically ill Medicare
beneficiaries in the last two years of life. The beneficiaries all died between 2001 and 2005, and
they were suffering from one or more of the nine chronic diseases listed above. The extent of varia-
tion in Medicare spending and utilization and the evidence that more care does not result in better
care or better outcomes indicate that some chronically ill and dying Americans receive too much
care: more than they or their families actually benefit from. Unlike the previous Atlas, this version
includes Medicare spending not just on inpatient care, but also the amount spent on ambulatory
care, skilled nursing care, long-term care, home health care, and hospice care. The final chapter of
this Atlas will outline a proposal for reforming the Medicare payment system, a plan that is intended
to simultaneously improve the quality of care for the chronically ill and rein in spending.
inTroDuCTion 1
EMBARGOED FOR RELEASE UNTIL APRIL 7, 2008 12:01 A.M. EDT
Dartmouth Atlas research has identified three categories of services that exhibit unwarranted
variation.
n Effective care consists of evidence-based interventions for which the benefits so far exceed
the harms that all patients in need should receive the service. Life-saving drugs following
heart attack are examples. Variations in the use of such treatments among eligible patients
reflect a failure to deliver needed care, or underuse.
n Preference-sensitive care encompasses treatment decisions where different choices carry
different benefits and risks, and where patients’ attitudes toward these outcomes vary. An
example would be the use of bypass surgery for heart disease, where surgery is likely to
improve patients’ chest pain but carries a small but real risk of causing memory loss. Unwar-
ranted variations in preference-sensitive care reflect both the limitations of current scientific
evidence and the failure to ensure informed patient choice.
n Supply-sensitive care refers to services where the supply of a specific resource (e.g., the
number of specialists per capita) has a major influence on utilization rates. Physician visits,
hospitalizations, stays in intensive care units, and imaging services are all examples of care
where the local supply influences the frequency of use. Variations in supply-sensitive care
are largely due to difference in local capacity, and a payment system that ensures that exist-
ing capacity remains fully deployed.
The focus of this Atlas is on the use of supply-sensitive care among Medicare patients with
severe chronic illness.
Why do some regions spend more and do more?
The previous version of the Dartmouth Atlas, The Care of Patients with Severe Chronic Illness,
published in 2006, documented the unwarranted variation in the care of chronically ill Medicare
beneficiaries in different regions of the country. That Atlas found extensive unwarranted variation
in both the quality of care and the amount of care delivered to Medicare recipients in the last two
years of life. For example, Medicare per capita spending on chronically ill beneficiaries varied more
than twofold among hospital referral regions.i Spending also varied from state to state, and from
one hospital to another, even among hospitals within the same region.
Most of this variation was not due to differences in the price of care in different parts of the country,
but rather to differences in the volume, or the amount of inpatient care delivered per capita. For
example, during the last two years of life, when chronically ill patients are typically very sick and
often suffering from multiple chronic diseases, Medicare recipients in one region spent as many as
30.3 days on average in the hospital over the course of their last two years of life, and as few as 11.7
i Hospital referral regions (HRRs) represent regional health care markets for tertiary medical care. Each HRR contains at
least one hospital that performs major cardiovascular procedures and neurosurgery.
2 The DarTmouTh aTlas of healTh Care 2008