Wednesday, April 22, 2009

Lack of Care Coordination

The switch from acute to complex chronic diseases and the wide variation in care patterns are closely related. It is the complex chronic diseases that need the most attention and hence are most expensive to treat. But as a country we have long had the tradition of the independent, autonomous practioneer in the community taking care of us. This was fine for acute illnesses. The physician could either treat you him or herself or else would refer you to a particular specialist for needed care. Maybe to the surgeon to remove your appendix or gallbladder. Once the surgery was done, the problem was “cured.” Not so with chronic illnesses. Often the patients need multiple physicians, each with different skills and expertise such as the cancer patient would need a surgeon, a radiation oncologist and medical oncologist. But these three and the primary care physician are not likely to be well coordinated. They may have offices in different parts of town and possibly use different hospitals for some of their work. Communication is weak and the PCP often does not feel able to serve as the coordinator or quarterback. And, since these chronic illnesses often occur in older individuals, there is a good likelihood that other illnesses will develop concurrently. Maybe high blood pressure, heart failure or diabetes with complications. And so off to more specialists who do not communicate well and who do not understand the implications of the other illnesses, the other medications, etc. the result is often extra doctor visits, extra procedures, tests and X-rays and even extra hospitalizations than would have been necessary with well coordinated care. Unfortunately, this is the way medicine is practiced today and it is a real problem. It means that care is not as good as it should be or could be, not as safe as it should or could be, not as customer [patient] friendly as it should be or could be, and it means that it costs far too much.

Thursday, April 9, 2009

Care Costs Vary By Geographic Region

When thinking about health care reform it is important to realize that there are wide variations in care expenditures from geographic region to region. One might assume that those regions with higher expenditures reap better health but that is simply not the case. Unfortunately, much of medical care is not delivered based on evidence of efficacy but rather on long standing practice, tradition or training many years before. Indeed there is some pretty firm data that suggests that where there are more specialists, and where there is “more capacity” that it will get used more and drive up the total cost of care. Some very interesting studies coming from Dartmouth Medical Center have tracked this over the years. In a recent analysis of Medicare data from 2001-2005, the Dartmouth investigators looked at the last two years of life for Medicare recipients with complex chronic diseases such as heart failure, kidney failure and dementia. They picked those two years of life because they account for about one-third of all Medicare expenditures. What they found was a wide variation in costs or expenditures due to a wide variation in the use of services such as specialists, intensive care unit days, hospital days and so on. And this related directly to local medical care capacity. Where there was more capacity, there was more use and therefore higher expenditures. On average these Medicare patients each accounted for about $46,000 of expenditures by Medicare during those last two years of life. But in states with high capacity like New Jersey the average expenditures per patient were $59,000 and in an area like North Dakota where capacity is relatively low the average expenditure was $33,000. Certainly a wide difference and yet they could find no significant difference in the quality of care or patient outcomes. So they made a suggestion. If the use rate across the country was equivalent to the use rate in Minnesota, which is also where the Mayo Clinic is located, Medicare would have saved $18 billion per year for each of the years 2001-2005. They were not suggesting trying to bring it down to the North Dakota expenditure rate but they were suggesting that there was no reason why it could not be brought down towards the national average, an average which just about everyone would agree can produce a very effective medical result. The Dartmouth investigators pointed out that the “variations allow us to rule out two overly simplistic explanations for spending growth. First ‘technology’ is clearly an insufficient explanation: residents of all US regions have access to the same technology.” Second, these regional differences cannot be caused by “differences in the current payment system” since they all were on fee for service Medicare plans. “The causes must therefore lie in how physicians and other respond to the availability of technology in the context of the fee-for-service payment system.” They studied physicians in various regions and were able to show that physicians in all regions recommended specific evidence-based interventions for similar problems. But those in high consumption of resources areas were much more likely to recommended discretionary services, such as referral to a subspecialist for typical esophageal reflux. It was this use of discretionary services that resulted in the wide variation in per capita spending.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).